Interspinous implant and instrument for implanting an interspinous implant

ABSTRACT

The present invention relates to an interspinous implant, intended to be implanted between two adjacent dorsal spines, each including an upper edge, a lower edge and two opposed lateral faces, wherein the implant includes at least one body with dimensions arranged so as to maintain or restore a distance between the adjacent edges of the two spinous processes and including at least two wings extending so that at least a part of each wing lies along at least a part of one lateral face of one of the two spinous processes and, additionally, at least one retainer for the implant, designed to retain the body of the implant between the two spinous processes and to be inserted from the same lateral face as the body.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.13/369,650 filed Feb. 9, 2012, and issuing as U.S. Pat. No. 8,696,709 onApr. 15, 2014, which claims priority under 35 U.S.C. §119 to FrenchPatent Application No. 11/55908 filed in FRANCE on Jun. 30, 2011, and toFrench Patent Application No. 12/51031 filed in FRANCE on Feb. 3, 2012,all of which are incorporated by reference.

TECHNICAL FIELD

The present invention relates to the field of intervertebral prostheses,and in particular to the field of interspinous implants intended to beimplanted between two adjacent spinous processes of two adjacentvertebrae. The present invention also relates to instruments forimplanting such an implant.

BACKGROUND

The vertebrae of the vertebral column each have a spinous process, withthe exception of the fused sacral and coccygeal vertebrae, where thisspinous process is a more or less discernible vestige. These spinousprocesses have materially the shape of a plate oriented in the sagittalplane, with an upper edge, a lower edge, two lateral faces and a crestpointing rearward of the patient. The edges and faces can be more orless rounded depending on the patient, but make it possible to definesurfaces on which an implant can bear. The interspinous space thatseparates two adjacent spinous processes has a variable size dependingon the patient and on the location within the vertebral column. Thisspace is generally filled by an interspinous ligament. In addition, thecrests are covered by the supraspinous ligament that runs over theentire vertebral column. The spinous processes are therefore attached toone another by interspinous ligaments and the supraspinous ligament.

Interspinous implants are generally used particularly for pathologiessuch as herniated discs or degenerative lesions, hyperlordosis(particularly in the aged), shrinkage of the vertebral canal (lumbarstenosis) treated without laminectomy, persistent chronic lumbar pain,particularly in the event of failure of conservative treatment,degenerative disease of an intervertebral disc in a location adjacent toa prior fusion, spondylolisthesis of a grade lower than 1, etc. Incertain cases, particularly the least severe pathologies, theinterspinous implant provides an alternative or preliminary measure tomore invasive measures. Thus, the implant may be used alone to maintainor restore the interspinous space to physiological values, particularlyby preserving the mobility of the spinous processes in certain cases. Inother cases, the interspinous implant can be used for vertebral fusion,particularly of the spinous processes but also in association with adisc fusion, for example.

Interspinous implants should make it possible to restore elevationbetween spinous processes and to maintain that elevation (to relievearticular facets, the nerve roots, the disc, etc.), particularly whileawaiting arthrodesis (bone fusion). They must be stable between spinousprocesses, particularly in the lumbar region, whether or not havingmeans available of anchoring to the spinous processes. In addition, itis desirable to have different implant heights and/or widths and/ordepths available, particularly to match them best to their implantationsites. In addition it is preferred, in some cases, to immobilize the twospinous processes, while in other cases it is preferable to retainmobility. It is also sometimes desirable to control the extent ofmobility, particularly bending and rotation motion of the vertebrae.

One problem relates to the stability of interspinous implants onceimplanted between two spinous processes. The implant must not becomedislodged from its setting between the two spinous processes.

The stability of the interspinous implant is most often conferred bylateral wings, blades, arms or legs whose width makes it possible forthem to spread over a relatively large area of the two adjacent spinousprocesses. The interspinous implants should, however, be able to lendthemselves to multi-level surgery, and it is desirable that two implantsbe implantable in two adjacent interspinous spaces. The implant musttherefore be stable between spinous processes, yet without having toogreat a bulk, so as to facilitate its implantation and/or allow its usein adjacent interspinous spaces.

Another problem relates to the invasiveness of the implantation. As ithappens, it is generally preferable for the implant to be easilyimplantable and that it not be necessary to free too great a space inthe interspinous space to be treated. It is also generally preferable toleave intact as many of the structures around the implantation site aspossible. A compact implant, therefore, would be desirable.

Implants including at least one body insertable through the interspinousligament are known from the prior art. Certain known implantsnecessitate, for their implantation, the total removal of theinterspinous ligament located between the two spinous processes involvedin the implantation, but sometimes also of at least a portion of theinterspinous ligaments of the adjacent spinous processes. Certainimplants also necessitate the removal of the supraspinous ligament, atleast in the portion located over the two spinous processes involved inthe implantation. These ligament removals are not desirable for thepatient because they risk destabilizing the vertebral column and hencethe implant, for example by increasing the risks of excessive motion ofthe spinous processes. Finally, these implants require the opening oftoo large an approach path for their insertion, usually by pushing awaythe surrounding tissues, which is not desirable for the patient for thesame reasons as well as for reasons of muscle dilapidation.

Therefore, to obtain the least invasive implant possible, not requiringthe opening of a large approach path, it is necessary to reduce the bulkof the implant and to limit the size of the implantation path. Theseconstraints are attended by a problem of difficulty in implantation,especially if one wants to open only one (side) face of access to thespinous processes. In fact, for the least invasive possible implantationfor example, an approach path passing only through a plane near thesagittal plane of the spinous processes might be desired, allowingimpingement for instance only on one side of the patient's vertebralcolumn, that is to say on only one lateral face of the spinousprocesses.

It will be noted that addressing the problem of invasiveness contributesadditional constraints to the problem of stability, in particularbecause reducing the dimensions for reducing invasiveness may inducerisks of stability. In this context, it is advantageous to offer asolution which allows invasiveness and stability to be reconciled.

SUMMARY

The present invention has as its object to mitigate certaindisadvantages of the prior art by offering an interspinous implant whichis less invasive, to allow simple insertion between two spinousprocesses, while still offering good stability between the spinousprocesses.

This goal is achieved by an interspinous implant, intended to beimplanted between two adjacent dorsal spinous processes, each includingan upper edge, a lower edge and two opposed lateral faces, wherein theimplant includes at least one body with dimensions arranged so as tomaintain or restore a distance between the adjacent edges of the twospinous processes and including at least two wings extending so that atleast a part of each wing lies along at least a part of one lateral faceof one of the two spinous processes and, additionally, at least oneretainer for the implant, designed to retain the body of the implantbetween the two spinous processes and to be inserted from the samelateral face as the body.

The assembly of the interspinous implant in two distinct pieces,particularly with a retainer added to the body of the implant, allowsthe implant to be implanted in a very non-invasive manner by aunilateral posterior approach, without dis-inserting the supraspinousligament, and passing through the interspinous ligament while minimizingdamage thereto, the implant being able to spread itself sufficientlyaround the interspinous space to allow the stable installation thereof.

In addition, in certain embodiments, the implant can be easilywithdrawn.

According to another feature, at least a portion of the retainerprojects to the lateral faces of the body opposite to those comprisingthe wings, once the implant is assembled with the retainer.

According to another feature, the retainer includes an insert and inthat the implant comprises at least one passage passing through at leastone part of the body and having a shape, dimensions and orientationarranged for insertion, through the body, of at least one insertincluding at least one curved plate retained within the body so that atleast a part of the said curved plate lies along at least a part of onelateral face opposite the at least one lateral face along which one winglies.

According to another feature, the insert is attached to the body by aretention mechanism.

According to another feature, the body includes two wings arranged onthe same lateral face of the implant so as to lie along the same lateralfaces of the two spinous processes, two passages being arranged in thebody for the insertion of two inserts each projecting toward one of thespinous processes so as to lie along the same, opposite lateral face thepassages being accessible for insertion of the inserts on the samelateral face as the wings so that the implantation between the spinousprocesses can be carried out from only one of the lateral faces thereof.

According to another feature, the body includes two wings arranged onthe same first lateral face of the implant so as to lie along the samelateral faces of the two spinous processes and a third wing located on asecond lateral face opposite the first so as to lie along the oppositelateral face of a first of the two spinous processes, a passage beingprovided in the body for insertion of an insert extending toward thesecond spinous process to lie along the same lateral face thereof as thethird wing, the passage being accessible for insertion of the insert onthe lateral face equipped with the two wings so that the implantationbetween the spinous processes can be carried out from a single one ofthe lateral faces thereof.

According to another feature, the body includes, on the side oppositethat provided with the two wings, at least one chamfer facilitating theinsertion of the body between the adjacent edges of the two spinousprocesses.

According to another feature, the body includes two wings each arrangedon one lateral face of the implant opposite the other wing and eachextending toward one of the two spinous processes, so that the wingseach lie along one spinous process, but on opposite lateral faces, theinsert being of substantially sigmoidal shape due to its plate includingat least two radii of curvature of opposite orientations, so that bothfaces of the plate include both a concave and a convex part, the passageand the insert being arranged in such a way that, when the insert islodged in the passage, at least one portion of the said convex parts ofthe two faces of the insert each lies along at least one part of thespinous processes, on the lateral faces opposite those which the wingslie along.

According to another feature, the wings are provided on the lateralfaces of the implant and the body includes upper and lower faces incontact with adjacent edges (E2, E3) of the two spinous processes, thebody including, on at least one of these upper and lower faces, near thelateral faces not having wings, at least one ridge preventing theimplant from disengaging from the space between the adjacent edges ofthe two spinous processes.

According to another feature, said ridge is chamfered toward at leastone lateral face of the implant to facilitate the insertion of the bodybetween the adjacent edges of the two spinous processes.

According to another feature, the retention mechanism includes at leastone stop for the insert coming, when the insert is lodged in the throughpassage, into contact with at least one surface of the body near thethrough passage and at least one flexible tab of the insert orientedsubstantially in the direction of the said stop and arranged, firstly,to fold away during the insertion of the insert into the through passageand secondly to unfold and to bear on a surface provided for thispurpose on the body.

According to another feature, said surface provided for the flexible tabis accessible from outside the body by a duct, so as to allowdisengagement of the flexible tab and withdrawal of the insert.

According to another feature, the stop and its abutment surface on thebody are so arranged that the stop does not project beyond the perimeterof the body.

According to another feature, at least one wing of the implant includesat least one point arranged so as to anchor itself in the lateral faceof the spinous process along which said wing lies.

According to another feature, the sigmoidal insert includes, on at leastone of its convex parts, at least one point arranged so as to anchoritself in the lateral face of the spinous process along which saidconvex portion lies.

According to another feature, at least one of the wings and/or at leastone insert includes at least one hole arranged to receive at least onepin of at least one bone anchorage device.

According to another feature, the sigmoidal insert includes, at one ofits ends, and indentation separating the curved plate into two branchesand including a bearing surface designed to receive a transverse bar ofa bone anchorage device including two pines perpendicular to said bar,the anchorage device being so arranged that, firstly, one of the pinsenters the hole in one wing of the implant while the other pin passesbetween the branches of the insert and so that, secondly, said bar bearson the bearing surface of the indentation in the insert and causes theinsert to enter the through passage of the implant when the pinspenetrate a lateral surface of the spinous processes.

According to another feature, said retainer comprises a complementarybody, superimposable on the body so that two wings of the complementarybody extending from the complementary body are each arranged on alateral face opposite to that of a wing of the implant's body, lockingresources being arranged to maintain the two bodies superimposed byfixing their position with respect to the other, so that the wings ofeach body maintain the orientation of the other body compared to the twospinous processes.

According to another feature, the complementary body has dimensionsdesigned to maintain the distance between the adjacent edges of the twospinous processes complements the body of the implant.

According to another feature, the wings of each of the two bodiesextend, on their face parallel to the sagittal plane, as far as thelateral face of the other body.

According to another feature, the two bodies are mounted so as to pivotrelative to one another about a rotation pivot designed to as to allowone portion of each of the wings of the complementary body to be placedin contact with a portion of a wing of the first body, to facilitate theinsertion of the implant between the spinous processes, and to thenallow deployment of the wings of the complementary body parallel to thesagittal planel, the locking means being designed to lock the wings ofthe complementary body in the deployed position.

According to another feature, the two wings of the body extend, on theirlateral face, to the lateral face of the complementary body and a singlewing of the complementary body extends, on its lateral face, to thelateral face of the body, while the other wing of the complementary bodydoes not extend substantially farther than the rest of the body, so asto facilitate the insertion of the complementary body onto the body whenthe later is already in place between the spinous processes.

According to another feature, the retainer of the implant includes atleast one flexible connector one end of which is affixed to a first ofthe two wings and which is located within the body so as to run overeach lateral face of the two spinous processes opposite to that alongwhich each wing lies.

According to another feature, the body has a passage for the flexibleconnector from one lateral face to the other between the two spinousprocesses.

According to another feature, the body has a locking means designed tolock the connector relative to the implant.

According to another feature, the passage running through the body fromone lateral face to the other follows an oblique path, orienting theflexible connector toward the portion of each lateral face not having awing.

According to another feature, the body includes upper and lower faces incontact with the adjacent edges of the two spinous processes, at leastone of said lower and upper faces being provided with at least onecushioning material.

According to another feature, the body includes upper and lower faces incontact with the adjacent edges of the two spinous processes, andincludes a material favoring bone growth to allow the fusion of theupper and lower spinous processes at least at the location of said lowerand upper faces.

According to another feature, at least one of the wings and/or at leastone insert is(are) provided with shapes and/or dimension designed sothat two implants can be implanted in two consecutive interspinousspaces of three adjacent vertebrae without having the wings or theinserts overlap, even partially.

According to another feature, the retainer comprises at least onespinous hooking resources arranged to hook around at least a portion ofan edge of a dorsal spinous process that is opposite to the edge againstwhich the body of the implant is affixed.

According to another feature, the hooking resources comprise at leastone hooking device distinct from the implant and including at least twoparts each comprising, on the one hand, a curved portion forming a sortof hook for hooking opposite edges of adjacent dorsal spinous processesand, on the other hand, an attachment structure of both parts formaintaining the spacing between these parts.

According to another feature, the attachment structure is adjustable,for adjusting the spacing between the two parts of the hooking device,so as to control the spacing of the hook-shaped portions and thereforethe spacing of the spinous processes.

According to another feature, the hooking device comprises linking orconnection resources to the implant and/or the insert.

According to another feature, the attachment structure of the hookingdevice has at least one ligament connecting the two parts together

According to another feature, the retainer comprises at least a portionof the insert forming a sort of hook arranged to hook, at theintroduction of the insert in the passage of the body, around a spinousprocess, on at least a portion of the edge which is opposite the edgeagainst which the body of the implant is affixed.

According to another feature, the hooking resources comprise at leastone hook pivotally mounted on the body of the implant and arranged tohook around a spinous process, on at least a portion of the edge whichis opposite the edge against which the body of the implant is affixed.

According to another feature, the hooking resources comprise at leastone end portion of a wing of implant forming a sort of hook arranged tohook around a spinous process, on at least a portion of the edge whichis opposite the edge against which the body of the implant is affixed.

According to another feature, the implant comprises compressionresources for compressing the lateral faces of at least one spinousprocess between at least one wing of the implant and a retainer of theimplant.

The present invention also relates to an instrument facilitating theimplantation of an interspinous implant which is poorly invasive.

This aim is attained by an instrument for implanting an interspinousimplant defined according to the invention, wherein it includes at leastone means for gripping the implant which includes at least one anchorageto receive the said gripping means and at least one actuating means,movable with respect to the gripping means and arranged so as to drivethe insert into the implant when it is actuated.

BRIEF DESCRIPTIONS OF VARIOUS VIEWS OF THE DRAWINGS

Other features and advantages of the present invention will appear moreclearly upon reading the following description, given with reference tothe appended drawings, in which:

FIGS. 1A, 1B and 1C show respectively a perspective view, a side viewand a top view of an interspinous implant according to certainembodiments;

FIGS. 2A, 2B and 2C show respectively a perspective view, a side viewand a top view of an interspinous implant according to certainembodiments;

FIGS. 3A, 3B and 3C show respectively a perspective view, a side viewand a top view of an interspinous implant according to certainembodiments;

FIGS. 4A and 4B show respectively a perspective view and a top view ofan interspinous implant according to some embodiments, FIGS. 4C and 4Dshowing respectively a perspective view and a top view of aninterspinous implant and of an insert according to certain embodiments;

FIGS. 5A, 5C and 5E show perspective view of sigmoidal inserts intendedto be retained within interspinous implants according to variousembodiments, FIGS. 5B, 5D and 5F showing side views of the inserts ofFIGS. 5A, 5C and 5E, respectively, FIG. 5G showing a view in profile ofthe insert of FIGS. 5E and 5F;

FIGS. 6A, 6C and 6E show perspective views of interspinous implantsaccording to various embodiments, FIGS. 6B, 6D and 6F showing top viewsof the implants of FIGS. 6A, 6C and 6E, respectively;

FIGS. 7A and 7C show perspective view of interspinous implants accordingto various embodiments, FIGS. 7B and 6D showing top views of theimplants of FIGS. 7A and 7C, respectively;

FIGS. 8A and 8B shows perspective views of an interspinous implant inthe free and locked condition, respectively, according to certainembodiments, FIG. 8C showing a top transparency view of the lockedconfiguration implant in FIG. 8B;

FIGS. 9A and 9B show longitudinal section views of interspinous implantsaccording to various embodiments;

FIGS. 10A, 10B and 100 show perspective views of an interspinous implantand a sigmoidal insert according to certain embodiments;

FIGS. 11A and 11B show a perspective view and a longitudinal sectionview, respectively, of an interspinous implant according to certainembodiments, and in the disassembled and assembled condition,respectively;

FIGS. 12A, 12B and 12C show a side view, a top transparency view and alongitudinal section view, respectively, of an interspinous implantaccording to certain embodiments;

FIGS. 13A through 13C show a top view and two perspective views fromopposite sides, respectively, of a series of two interspinous implantsaccording to certain embodiments;

FIGS. 14A and 14B show a perspective view and a longitudinal sectionview, respectively, of an implantation instrument for interspinousimplants according to certain embodiments, FIG. 14C showing anenlargement of the area 14C indicated on FIG. 14B;

FIGS. 15A through 15B show two perspective views of an instrumentequipped with actuating means for insertion of an insert into the bodyof an interspinous implant according to certain embodiments, in thedeployed and in the actuated position, respectively, FIG. 15C showing anenlargement of the area 15C indicated on FIG. 15B;

FIGS. 16A and 16B show perspective views oriented to the oppositelateral faces of two adjacent vertebrae in the vertebral column,illustrating the spinous processes, the sagittal plane of the vertebralcolumn and a three-dimensional benchmark used as a reference;

FIGS. 17A, 17B and 17C show three perspective views of an interspinousimplant before, during and after its implantation between the twospinous processes, respectively, according to certain embodiments

FIGS. 18A, 18B and 18C show, respectively, two top views and aperspective view of an interspinous implant according to someembodiments, FIG. 18A representing the implant when assembled with abone anchor and FIGS. 18B and 18C representing the implant during itsassembly with the bone anchor,

FIGS. 19A, 19B and 19C show, respectively, two top views and aperspective view of an interspinous implant according to someembodiments, FIG. 19A representing the implant when assembled with abone anchor and FIGS. 19B and 19C representing the implant during itsassembly with the bone anchor,

FIGS. 20A and 20B respectively represent a perspective view and a topview of an interspinous implant having hooking resources and boneanchoring resources according to some embodiments,

FIGS. 21A and 21B are perspective views of an interspinous implanthaving hooking resources on a wing and on the insert, according to someembodiments, and FIGS. 21C and 21D are respectively a side view and atop view of an insert provided with hooking resources according to someembodiments,

FIGS. 22A and 22B respectively represent a side view and a top view ofan implant and a hooking device according to some embodiments, and FIGS.22C and 22D are respectively a side view and a view top of a hookingdevice according to some embodiments,

FIGS. 23A and 23B are perspective views of an implant and a hookingdevice according to some embodiments and FIGS. 23C and 23D arerespectively a top view and a perspective view of a hooking deviceaccording to some embodiments,

FIGS. 24A and 24C show two perspective views of an instrument equippedwith actuating means for inserting an insert into the body of aninterspinous implant according to some embodiments, respectively in anextended position and in an actuated position, FIG. 24B showing anenlargement of the area 24B indicated on FIG. 24A and FIG. 24D showingan enlargement of the area 24D indicated on FIG. 24C,

FIGS. 25A and 25B show respectively a perspective view and a top cutawayview of an interspinous implant according to certain embodiments; FIGS.25C and 25D show top views of this implant respectively during itsimplantation and after its implantation between two adjacent spinousprocesses,

FIGS. 26A and 26B show respectively left and right posterio-lateralperspective views of an interspinous implant according to certainembodiments, implanted between two adjacent spinous processes,

FIGS. 27A and 27B show a perspective view of an interspinous implantaccording to certain embodiments, respectively assembled anddisassembled; FIGS. 27C and 27D show perspective views of aninterspinous implant according to certain embodiments, in the folded andin the unfolded position respectively; FIGS. 27E and 27F showperspective views of an interspinous implant according to certainembodiments, assembled and disassembled respectively,

FIGS. 28A and 28B show respectively a top and a perspective view of aninterspinous implant according to certain embodiments, implanted betweentwo adjacent spinous processes; FIG. 28C shows a perspective view of aninterspinous implant according to certain embodiments, with flexibleconnector locking means disassembled, and FIG. 28D shows a perspectiveview of an insert for an interspinous implant according to certainembodiments,

FIG. 29A shows a top view of an interspinous implant according tocertain embodiments, implanted between two adjacent spinous processes,and FIG. 29B shows a perspective view of an interspinous implantaccording to certain embodiments

FIGS. 30A and 30C show two perspective views of an interspinous implantplaced between two spinous processes according to some embodiments,respectively, during and after implantation, FIG. 30B shows anenlargement of the portion 30B shown in FIG. 30A and FIG. 30D shows anenlargement of the portion 30D shown in FIG. 30C, FIG. 30E showing a topview of the implant according to these embodiments,

FIGS. 31A, 31C and 31D show perspective views of an interspinous implantplaced between two spinous processes according to some embodiments, FIG.31B shows an enlargement of the portion 31B shown in FIG. 31A and FIG.31E showing a view top of the implant according to these embodiments,

FIGS. 32A and 32B are perspective views of an interspinous implantplaced between two spinous processes according to some embodiments;

FIGS. 33A and 33B are perspective views of an interspinous implantplaced between two spinous processes according to some embodiments;

FIGS. 34A and 34B are respectively a perspective view and a top view ofan interspinous implant placed between two spinous processes accordingto some embodiments;

FIGS. 35A and 35B are respectively a perspective view and a top view ofan interspinous implant placed between two spinous processes accordingto some embodiments;

FIG. 36A shows a bottom perspective view of an interspinous implantaccording to certain embodiments and FIGS. 36B and 36C show two bottomviews of this implant, respectively before and after compression of thespinous processes;

FIGS. 37A and 37C show perspective views of an interspinous implantaccording to certain embodiments, respectively before and after pivotingof a latch for compressing the spinous processes and FIGS. 37B and 37Dshow section views, along the section planes 37B and 37D respectively,of the implant of FIGS. 37A and 37C, respectively;

FIGS. 38A and 38C show perspective view of an interspinous implantaccording to certain embodiments, respectively before and after pivotingof a latch for compressing the spinous processes. FIGS. 38B and 38D showsection views along the planes 38B and 38D, respectively, of the implantof FIGS. 38A and 38C, respectively;

FIGS. 39A and 39C show perspective views of an interspinous implantaccording to certain embodiments similar to those of FIGS. 38A and 38C,respectively before and after pivoting of compression resources for thespinous processes. FIGS. 39B and 39D show section views along sectionplanes 39B and 39D, respectively, of the implant of FIGS. 39A and 39C,respectively;

FIGS. 40A and 40B show respectively a coronal (i.e. frontal) sectionview and a perspective view of an interspinous implant according tocertain embodiments. FIGS. 40C and 40D show respectively a top view anda perspective view of an interspinous implant according to certainembodiments closely related to those of FIGS. 40A and 40B;

FIGS. 41A and 41C show perspective views of an interspinous implantaccording to the embodiments of FIGS. 40A and 40B, respectively beforeand after pivoting of a plug for compressing the spinous processes andFIGS. 41B and 41D show section views along the section planes 41B and41D respectively, of the implant of FIGS. 41A and 41C, respectively;

FIGS. 42A and 42B show respectively a perspective view and an explodedview of an arrangement for retaining an interspinous implant in thefolded position according to certain embodiments, FIG. 42C showing aperspective view of this retaining arrangement in the deployed position;

FIGS. 43A and 43B show respectively a perspective view and a sectionview in section plane 43B of FIG. 43A, of an interspinous implantaccording to certain embodiments, in which is inserted, in the foldedposition and held by a pin, a retaining arrangement of the typeexemplified in FIGS. 42A, 42B and 42C, FIGS. 43C and 43D showingperspective views of this implant of FIG. 43A without the pin and withthe retaining arrangement in the deployed position;

FIG. 44A shows a perspective view of an embodiment of an implantationinstrument for various embodiments of an interspinous implant, forexample the embodiments of FIGS. 43A, 43B, 43C and 43D, and FIG. 44Bshows an enlargement of portion 44B of FIG. 44A, showing the end of theinstrument bearing an exemplary implant;

FIGS. 45A and 45B show perspective views of an embodiment of a retainerfor various embodiments of an interspinous implant, forming compressionresources for spinous processes, according to some embodiments, and,respectively, in a folded position and a deployed position, and FIG. 45Cshows a perspective view of a similar retainer, but according to otherembodiments;

FIGS. 46A and 46B show perspective views, respectively, of an embodimentof a retainer for various embodiments of interspinous implants and of aninterspinous implant equipped with such a retainer forming compressionresources of spinous processes, according to some embodiments;

FIG. 47A shows a perspective view of some embodiments of an instrumentfor compressing spinous processes by actuating an embodiment of aninterspinous implant equipped with compression resources, FIG. 47B showsan enlargement of the area 47B in FIG. 47A and FIG. 47C shows the sametype of enlargement, but when compression is performed;

FIG. 48A shows a perspective view of some embodiments of an instrumentfor compressing spinous processes by actuating an embodiment of aninterspinous implant equipped with compression resources, FIG. 48B showsan enlargement of the area 48B in FIG. 48A and FIG. 48C shows the sametype of enlargement, but when compression is performed.

DETAILED DESCRIPTION OF VARIOUS EMBODIMENTS

The present invention concerns an interspinous implant (1) intended tobe implanted between the spinous processes (dorsal vertebral apophysesor feather bones or spinal crests) of two adjacent vertebrae. In thepresent application, the spinal crests or spinous processes of thevertebrae are designated by the terms “vertebral spine”, “dorsal spine”,“spinous processes” or quite simply “spine” (while the vertebral columnwill therefore be called “rachis” instead of the commonly used term“spine”). The spinous processes are the rearmost structures of thevertebral column and therefore potentially afford the quickest access(they can actually be palpated below the skin from C7 to L5), whichmakes certain interspinous implants easy to implant but can impose thestability and implantation constraints discussed in the presentapplication. Thus the space that separates two adjacent spinousprocesses is designated in the present application by the terminterspinous space. Certain embodiments allow the insertion of severalimplants between the consecutive interspinous spaces of several (morethan two) adjacent vertebrae, as detailed in the present application.

The dorsal spines (EI, ES), generally substantially aligned in themedian sagittal plane (or approximately oriented in that plane), havematerially the shape of a disc or plate, of generally oblong or ellipticsection in the coronal plane, with an extremity (a crest) pointingrearward of the patient. The spinous processes have, referring to thelongitudinal axis of the vertebral column, an upper edge (E2), a loweredge (E3) and two opposite lateral faces (E4, E5).

FIGS. 16A and 16B showing schematically perspective views of theconstitutive elements of two adjacent vertebrae, with the mediansagittal plane (A) and a Cartesian benchmark (X, Y, Z) which is used asa reference in the present description for the sake of simplification.These figures show a lower vertebra (VI) with its spinous process, alsocalled lower (EI), and an upper vertebra (VS) with its spinous process,also called upper (ES) and show the edges (E2, E3) and faces (E4, E5) ofeach of these upper (ES) and lower (EI) spinous processes. The presentapplication describes certain elements of the implant with reference toits positioning once implanted in the body of the patient, for greaterclarity regarding the localization of the various elements of theimplant with respect to the vertebral structures. In FIGS. 16A and 16B,the patient is considered to be in a horizontal position, lying facedown. The Cartesian benchmark shown comprises three mutually orthogonaldirections (X, Y, Z). The X direction corresponds to the risinglongitudinal axis of the vertebral column, the Y direction correspondsto the anteroposterior axis and the Z direction corresponds to themediolateral axis. Thus the X and Y axes define a sagittal plane (A),the X and Z axes define a coronal plane and the Y and Z axes define atransverse plane of the patient. The present application will be able torefer to these patient planes for the implant itself, since the implantis intended to be implanted with its wings located to either side of thesagittal alignment plane of the spinous processes, as can be seen inparticular in FIGS. 17A through 17C. The terms “upper” and “lower” aretherefore used in the present application with reference to the X axis.A top view is a view by which the vertebral column or the implant isseen from behind the patient lying face down and a side view is a viewby which the vertebral column or the implant is seen from a lateral faceof the vertebral column or of the implant according to the samereference. These view and orientation considerations are usedindependently of whether the implant is implanted or not, and it will beunderstood that they relate to the implant in its implantation site butthat they are not limiting. In addition, it will also be understood fromthe present application that the implant can be reversed depending onthe face of the vertebral column through which the surgeon wishes toapproach the interspinous space. Further, it will be understood that theinvention allows the spinous processes to be approached through onelateral face of the vertebral column, but the approach is preferably notcarried out perpendicularly to the sagittal plane (along the Z axis),but rather substantially parallel to the Y axis or preferably along anoblique axis which is oriented rearward of the patient (an axis orientedbetween the Y and Z axes, but also eventually non-parallel to the X axisif necessary). It will be understood, however, that the insertions ofthe implant and of the insert are preferably performed substantiallyparallel to the Z axis. Finally, still referring to these benchmarks onthe patient, the terms “height” (particularly of the implant) or“length” (particularly of the wings or of the insert) are used todesignate a dimension along the X direction, the terms “width”(particularly of the implant) or “thickness” (particularly of the wingsor of the insert) to designate a dimension along the Z direction and theterm “depth” to designate a dimension along the Y axis. Said terms usedfor dimensions along the axes and directions of the benchmark are notlimiting and do not signify that the elements in question arenecessarily oriented exactly along the axis referred to and thisreference could refer to their orthogonal projection onto the axis ortheir dimension along an axis approximately oriented in the samedirection as the axis referred to.

Various embodiments of the interspinous implant have a longitudinal body(10) with dimensions arranged so as to maintain or restore a distancebetween the adjacent edges (E2, E3) of the two spinous processes (EI,ES) between which it is intended to be implanted (the adjacent edgesmeaning here the neigbouring edges of two successive spinous processes,that is to say two edges of spinous processes facing each other). Infact, an interspinous implant is intended to be inserted between twospinous processes (EI, ES) to maintain the space separating them at aphysiological value (or possibly a corrective value, that is a valueimposing lordosis or kyphosis). The surgeon therefore may select apredetermined height of the body (10) of the implant according to thespacing that he wishes to maintain (or to restore in the case ofinsufficient spacing) between the two adjacent spinous processes (EI,ES) of interest. In various embodiments, the implant (1) includes atleast two wings (11, 12) (or arms or blades or legs) extending in such away that at least part of each wing (11, 12) lies along at least a partof a lateral face (E4, E5) of one of the two spinous processes (EI, ES).Thus, in these embodiments, each wing of the implant extends from thebody (10) embedded in the interspinous space to a lateral face (E4, E5)of one of the spinous processes (EI, ES). The implant (1) includespreferably only two wings (11, 12) so as to facilitate its implantationbetween the spines (EI, ES). The interspinous implant (1) can also beinserted between the spines from a single lateral face of the vertebralcolumn and its wings (11, 12) constitute extensions which stabilize thebody (10) in the interspinous space by extending beyond thatinterspinous space (each lying alongside a lateral face of one spine).Further, the implant (1) includes at least one retainer (2, 3, 4, 7,111, 121, 221, 24, 28, 29, L, 90) for the implant, designed to retainthe body of the implant between the two spines. This retainer (orretaining resources or arrangement) is designed to constitute aretention structure for the implant with respect to the two spines, thatis it avoids allowing the body to migrate within the interspinous space,or become dislodged from it. The wings, in their function of retainingor supporting the implant between the spines, are therefore supplementedby this retainer, preferably in that at least a portion of this retaineris located at the spine faces opposite those along which the wingsalready lie, once the implant is assembled with this retainer. The term“at” is used here because it will be understood from reading the presentapplication that this portion of the retainer can lie against, or near,or even across these faces opposite to those along which the wings lie.It will be noted that the term “at least one” retainer is used herebecause there can be several retainers of the same type or of differenttypes because the various embodiments of this at least one retainer areoften not mutually exclusive. It will be noted that this function ofretention or support is mainly oriented medio-laterally, that istransversely to the axis of the vertebral column (that is along the Zaxis) but that in certain embodiments the retainers also offerantero-posteriorly oriented support (along the Y axis) and/orlongitudinally oriented support (along the X axis). Preferably, the atleast one retainer (2, 3, 4, 7, 111, 121, 221, 24, 28, 29, L, 90) isdesigned to be implanted from a single lateral face of the vertebralcolumn, preferably the same one as that through which the body (10) ofthe implant (1) is implanted. An implant is thus obtained which is easyto insert and minimizes the lesions needed for its implantation. Indeed,the assembly of the interspinous implant from distinct parts, inparticular a body and at least one retainer, allows the implant to beeasily implanted in a very non-invasive manner by a posterior unilateralapproach (that is from a single lateral face, for example along anoblique axis drawn between the Y and Z axes) without withdrawing (orcutting or too greatly wounding) the subspinous ligament and passingthrough the interspinous ligament while minimizing damage to the lastmentioned. Thus, this configuration allows the implant to extendsufficiently within the interspinous space and at its edges to allow itto be installed in a stable fashion.

According to various embodiments that are not necessarily mutuallyexclusive, the at least one retainer (2, 3, 4, 7, 111, 121, 221, 24, 28,29, L, 90) of the implant (1) can include:

two curved inserts (2), as for example in the embodiments shown inPlates 1 and 2 of the figures,

one curved insert (2), in the case of a body (10) including a third wing(17), as for example in the embodiments shown in Plate 3 of the figures,

one insert (2) with two radii of curvature having opposite orientations,such as a sigmoid-shaped insert, as for example in the embodiments shownin drawing Plates 5, 10, 13 or 17 of the figures,

a complementary body (90), for example substantially symmetrical withrespect to the body (10) of the implant (1), as for example in theembodiments shown in drawing Plate 27 of the figures.

Furthermore, in certain embodiments, the at least one retainer (2, 3, 4,7, 111, 121, 221, 24, 28, 29, L, 90) provide(s), in addition to thefunction of retaining or holding the implant between the spines, afunction of retaining or maintaining the two spines relative to oneanother. Indeed, even with an implant inserted between the two spines,the last mentioned are possibly able to move relatively to one another,in particular during rotational or extensional motion of the vertebralcolumn. Thus, in certain embodiments, the at least one retainer (2, 3,4, 7, 111, 121, 221, 24, 28, 29, L, 90) allow(s) the two spines to beretained relative to one another (and generally with respect to theimplant). For example, in certain embodiments of the inserts (2) and/orof the supplementary bodies (90), the two spines can be held inalignment in the same sagittal (or possibly para-sagittal if thepatient's vertebral column requires it) plane. In addition, variousembodiments of the at least one retainer also allow the two spines to beheld at a maximum spacing or within a determined range of spacings (theminimum spacing being imposed by the height of the body as explainedabove). According to various embodiments which are not necessarilymutually exclusive, the at least one retainer (2, 3, 4, 7, 111, 121,221, 24, 28, 29, L, 90) of the implant, also constituting at least oneretainer of the spines, can include:

at least one flexible connector (L), also called a ligament (L), as forexample in the embodiments shown in drawing Plates 25 and 26 of thefigures,

at least one bone anchorage means, such as points (111, 121, 221),particularly threaded ones, staples (3), anchors (7), pivoting hooks(28), or even antiskid notches (29), as for example in the embodimentsshown in drawing Plates 4, 6, 7, 8, 11, 18 and 19 of the figures,

at least one additional means of hooking onto a spine, such as hooksdesigned to achieve a grip on the edges of the spines, whether formed bythe insert (for example as on drawing Plate 21), or mounted on theinsert (for example as on drawing Plate 20) and/or the implant, orseparate from the rest of the implant and attachable or not, as forexample in the embodiments shown in Plates 20, 21, 22 and 23 of thefigures.

The present application describes in detail the possible arrangementsfor these various types of the at least one retainer (2, 3, 4, 7, 111,121, 221, 24, 28, 29, L, 90), as well as their respective advantages.

Thus, in certain embodiments, the implant (1) includes, firstly, atleast two wings (11, 12) extending so that at least a portion of eachwing (11, 12) lies along at least a portion of a lateral face (E4, E5)of one of the two spines (EI, ES) and additionally, at least one passage(15) passing through at least a portion of the body (10). In variousembodiments, this passage has a shape, dimensions and orientationarranged for the insertion, through the body (10), of at least oneinsert (2). In various embodiments, the insert (2) may include at leasta curved plate and is retained within the body (10) so that at least apart of said curved plate lies along at least a part of a lateral face(E5, E4) opposite a lateral face (E4, E5) having a wing (11, 12) lyingalong it (at least one of the lateral faces when the implant lies alongboth faces, as detailed in some embodiments of the present application).It is understood that this results in at least one wing of the implantlying along a lateral face of a spinous process, the other lateral faceof which has at least a part of at least one insert lying along it. Inthese embodiments, this configuration allows the body to be insertedfrom a lateral face opposite which will be arranged a wing, and then aninsert (2) to be inserted in the passage (15) of body (10), by the samelateral face, with a curved part of the insert (2) making it possible toposition the insert (2) facing the opposite lateral face (located on theother side of the spinous process, and to which there is therefore nodirect access).

In the present application, the term “wing” designates an element of theimplant (1) which extends in the direction of the lateral faces of thespinous processes (generally longitudinally and substantially along theX axis) and should not be interpreted in a limiting way because thewings can have various shapes, some examples of which are detailed inthe present application. It will be noted in particular that the wingsare preferably not hinged to the body and are in fact extensions of thebody (for example on the lateral faces or on the upper and lower faces,or rather at the junction of these faces). If these wings were hinged,they would have to include a locking mechanism for the hinge so as tofulfill their function of retaining the implant. Generally, the wings(which could be called arms, legs, extensions or something else) can bein the form of a straight or curved plate and will preferably haveshapes and dimensions designed for good holding of the implant betweenthe spines. Generally, the wings (which could be called arms, legs,extensions or else) can be in the shape of a straight or curved plateand will preferably have shapes and dimensions suited to good retentionof the implant between the spinous processes. For example, in the caseof curved wings, the insertion of the implant will be facilitated inmany embodiments (particularly embodiments where the wings are not onthe same lateral face of the implant) and the free end of the curvedwings will be closer to the lateral faces of the spinous processes thanthe rest of the implant or even in contact with these lateral faces toallow good retention of the implant between the spinous processes. Thedimensions of the wings can also be matched to the dimensions of thelateral faces of the spinous processes. For example, the wings can havea length (along the X axis) on the order of half that of the lateralfaces of the spinous processes or even greater (which may beparticularly advantageous for providing stability and which is possibleeven in certain embodiments where the wings have shapes arranged toallow the implantation of several implants in consecutive interspinousspaces of several consecutive vertebrae of the vertebral column, forexample as detailed in the present application). The depth of theimplant can generally vary according to the size of the spinousprocesses along the Y axis and/or the surgeon's preference, to offermore or less support for the spinous processes, thanks to contact with amore or less extensive surface on the upper and lower edges of thespinous processes. This depth can also be determined according to thedesired total volume of the implant, to minimize the injuries necessaryfor its implantation. Thus the body (10) can have a depth so determinedand the wings (11, 12) can have a substantially identical or differentdepth. Moreover, the depth of the implant, of the body and/or the wingsin particular, can vary over the height of the implant, for example asshown in FIG. 1B where it can be seen that the free end of the wings hassmaller dimensions than the rest of the implant so as to facilitate theinsertion of the wings into the interspinous space.

Generally, the wings (11, 12, 17) have a shape and dimensions arrangedso as to facilitate the positioning of the implant (1) between the twodorsal spines (EI, ES) while still ensuring good retention onceimplanted. The verb phrase “to lie along” (or “run”) is used in thepresent application because the wings (11, 12) of the implant (1) arearranged so as to lie along the lateral faces of the spinous processes(EI, ES) but are not necessarily in contact therewith. These wings maybe straight or curved and may or may not be parallel to said lateralfaces, so that the implant can for example have an H or X shape viewedfrom the top or in section in the coronal plane (i.e., frontal plane),with a wing (11, 12) forming a half-branch of the H or the X and a partof the insert (2) or inserts (2) protruding outside the body (10)forming another half-branch of the H or the X. In addition, the implant(1) may have a shape and dimensions arranged so that a slight lateralplay is or is not possible (along the Z axis), to allow or not allowrelative motion of the dorsal spines (EI, ES), that is a torsionalmotion obtained by relative rotation of the vertebrae with respect toone another (for example, when the patient turns to one side). Thus thespacing between a wing and the part of the insert that faces it (on theopposite face) can vary depending on the width of the spinous processesand/or on the play that may be desired. Similarly, the body (10) canhave a variable width, but it is the spacing between a wing and the partof the insert that faces it that matters because the body can have awidth greater or smaller than this spacing without necessarilyinfluencing the possible play of the spinous processes. If no play isdesired, the implant can be arranged so that there is contact on bothfaces of each spinous process, to prevent any movement. In the casewhere lateral play is possible, the amplitude of the last-mentioned canbe selected so as to limit or not the relative motions of the spinousprocesses by adjusting the spacing between each wing and the part of theinsert that faces it. It is possible for example to change the positionand/or the orientation of the passage (15) and/or the radius (radii) ofcurvature of the insert (2).

As regards the implant which is intended to be inserted into theinterspinal space through a lateral face of the vertebral column, theterm “front” or “anterior” lateral face is used to designate the lateralface of the implant that is inserted first, while the term “back” or“posterior” lateral face is used to designate the lateral face whichremains on the lateral face of the vertebral column through which theinterspinous space is approached. It is therefore understood that theinsert is inserted into the passage by the back lateral face, while thepassage outlet can be on the front lateral face or on either the upperor lower face or even at the junction between the front lateral face andone of the last-mentioned. As for inserts that project, once placed inthe passage directed toward the spinous processes, it is also possibleto define lateral faces on which occur the concave and convex faces ofthe curved plate. As the insert has a direction for insertion into theimplant, the term “anterior” or “front” is used to designate an elementwith respect to the anterior end which corresponds to that insertedfirst, and the term “posterior” or “back” is used to designate anelement with respect to the posterior end which corresponds to the endby which the insert is pushed into the passage in the implant. As theinsert is generally in the form of a plate, it is understood that thelength of the insert refers to the dimension from between the anteriorand posterior ends of the plate, while the width refers to the smallerdimension of said plate. The terms thickness and edges of the plate orof the insert are generally well understood by one skilled in the art,particularly because the other dimensions of the insert are definedhere.

The interspinous implant (1) of various embodiments has a body (10)having at least two wings (11, 12) and at least one passage (15)arranged to receive at least one insert (2) retained within the body(10) once it is inserted into the passage (15) until a portion of theinsert (i.e. part of its length) projects from the outlet of the passageto face the wing on the lateral face other than the one where the insertwas inserted, so that the implant lies along at least a part of the twolateral faces of the spinous processes (with or without contact),whereby the implant is held stably and is not liable to disengage fromthe interspinous space. It can be considered that the implant (1)includes the insert (2) as they are arranged to be assembled togetherinto a final implant. Nevertheless, implant bodies can be provided withother types of inserts than those described in the present applicationor, conversely, other bodies can be used with the same types of insertsas those described in the present application. In addition, because theinsert has advantageous features as a retainer for the interspinousimplant, it can be considered as an invention and claimed as such, forexample in its use with at least one implant including a passage forsuch retainer.

Preferably, the trajectory of the passage(s) (15) through the body (10)is substantially rectilinear in order to facilitate its manufacturing.Moreover, the insert is preferably arranged so as not to be flexible andnot to deform while passing in the passage, for example due to itsmaterial and/or its dimensions. Thus, once lodged in the implant inplace in the patient, the insert is not liable to deform under theeffect of movements of the spinous processes when the patient moves. Aslight possible deformation of the insert and/or the body cannevertheless be provided for, but it must then have sufficientelasticity to return to its position of rest. Thus, care shouldpreferably be taken to provide an insert which allows stable retentionand which will not deform excessively or definitively during itsinsertion or under the effect of movements of the spinous processesand/or which won't definitively deform the body. Thus, with arectilinear passage trajectory and a curved insert which is not insertedby deformation within the rectilinear passage, it is understood that itis preferable that the passage have dimensions (a height) greater thanthe thickness (height) of the insert and suited to the radius ofcurvature of the insert, so that the insert can pass without definitivedeformation of the insert and/or the body. In certain embodiments,however, passages (15) could be provided with a curved trajectorymatching the curve of the insert (2), though that necessitates morecomplex machining and/or assembly of the body in two parts or a curvedcore in the case of molding. For example, in the case of certainmaterials, certain known machining techniques allow a curved passage tobe provided and in the case of molding, it's possible to provide for acurved core to be inserted in the mold, but these techniques complicatethe manufacture. Moreover, in certain embodiments inserts (2) may bedeformable, preferably in an elastic manner, particularly in the case ofinserts (2) designed to be anchored in the spinous processes. In fact,anchorage in the spinous processes offers greater stability to theimplant and reduction of the risk of migration of the implant, even ifthe insert deforms under the effect of loads. Finally, the passage (15)is preferably slightly flared at its entrance and/or outlet tofacilitate the placement of the insert (2) within the body (10).

In some embodiments, in particular when the passage, generallyrectilinear, has a height greater than the thickness of the plate of theinsert (2), the height and length of the passage (15) are preferably set(arranged) according to the thickness and radius of curvature of theplate of the insert (2), and vice versa, so that the insert has at leastthree points of contact in the passage (15) when it is completelyinserted (final position) in said passage, at least two of these contactpoints being on opposite sides of the insert (2), so that the latter hasminimal clearance in the passage. For example, FIG. 11B shows asectional view with the sigmoid insert (2) in its final position thathas, with the walls of passage, a point of contact by the concave sideof its anterior near the exit of the passage, a point of contact by theconvex face of the anterior end near the transition between the tworadii of curvature of the sigmoid plate and a point of contact by theconvex face of the posterior end near the transition between the tworadii sigmoid curvature of the plate. It is seen from this figure that afourth point of contact is possible by the concave side of the posteriorend near the entrance of passage. It will be understood that in suchembodiments, the insert (2) is usually inserted in the passage with aslight reversible deformation (of the insert and/or body) and that thecurvature of the insert is arranged as a function of the dimensions ofthe passage (and vice versa) so that the insert (2) limits its play inthe passage, once implanted, by contacting the walls of the latter atseveral contact points or surfaces. The insert (2) thus has virtually noclearance in the passage and the only play allowed is due to theelasticity of the insert (2) and/or body (10). A slight deformation ofthe insert and/or body will therefore generally occur during theintroduction of the insert, which may have both sides contacting withthe walls of the passage and stabilizing the insert in the passage.

In some embodiments, in particular when the passage, generallyrectilinear, has a height greater than the thickness of the plate of theinsert (2), the latter comprises a thickening, a protrusion or a boss,arranged to come into contact with a wall of passage (15), so that bothsides of the plate of the insert (2) come into contact with the walls ofthe passage at the level of this thickening, thereby stabilizing theinsert (2) in the passage (15). This thickening of the insert (2),allowing contact with the walls of the passage, makes it possible tolimit the play of the insert in the passage. Preferably, this thickeningis progressive along the insert's anteroposterior direction, so that itmay gradually press the insert in the passage while avoiding them to beinjured. Thus, for example, the thickening may comprise, at least at itsfront end, at least one chamfer. Furthermore, in embodiments where thepassage includes at least one flare at its entrance (the portion thatreceives the insert first), the insert may include a portioncomplementary to this at the entrance of passage to stabilize theinsert. Thus, the thickening of the insert may be arranged to makecontact with the flare of the passage. Moreover, in some advantageousembodiments, the thickening or boss is formed by part of the insertionstop (25). For example, in FIGS. 9A and 9B, the insertion stop (25)shown actually forms a thickening for stabilization in the passage, inaddition to forming an insertion stop. This thickening is complementaryto the flare at the entrance of passage and therefore enables tostabilize the insert at the level of this flare. Note also that invarious embodiments, the abutment surfaces of the insertion stop (25) orwithdrawal stop (20) of the insert (2) are not necessarily completelyfacing the anterior or posterior ends of the insert, but it is possiblethat they are inclined. For example, in these embodiments of stops inthe shape of a thickening complementary to the flare, the stop surfaceis inclined with respect to the anterior and posterior ends, but thestop function is assured, in particular with another surface of theinsert (e.g., the face of the insert opposite to that on which the stopin question is formed). Thus, in some embodiments, the stop surface maynot be facing the ends of the insert, generally thanks to anothersurface of the insert, complementing this stop surface (for example asurface present on the face or edge of the insert opposite to the faceor edge bearing the stop concerned.

In certain embodiments, at least the front (or anterior, that is the oneinserted first) end of the insert can include at least one chamfer on atleast one of the faces of the plate and/or on at least one of the edgesof the plate. It is however generally preferred that the edges of theplate not be chamfered so that the entire width of the plate offers asupporting or retaining service for the lateral faces of the spinousprocess. It is therefore generally preferred not to reduce thedimensions of the plate by an edge chamfer. The chamfer on at least oneface (for example, concave and/or convex) of the plate offers variousadvantages. A chamfer at the front end can facilitate the insertion ofthe insert into the passage and/or help the passage of the insert alongthe spinous process, particularly if tissues are adhering to the spinousprocess. It is also generally preferred that the insert not be toopointed to avoid the risk of injury to surrounding tissues. A chamfercan then be provided, but arranged so that the chamfered end does notform a cutting edge. A chamfer at the front end of the concave face ofthe curved plate, as can be seen for example in FIG. 1C, allows the endto offer a surface oriented substantially along the orientation of thelateral face of the spinous process along which it lies, while otherparts of the insert do not have the same orientation due to thecurvature of the insert. In the case of inserts both of whose ends areintended to lie along the spinous processes, the same type of chamfercan be provided at both ends. In addition, to avoid injury to thesurrounding tissue, the ends of the insert can be provided with roundededges, or at least arranged so that they don't form corners that are toosharp.

Advantageously, the insert (2) is retained within the body (10), and mayeven be attached to it. Stop mechanisms or retention resources (20, 25)are described in the present application as examples of insert retention(stop or attachment, fixation) mechanisms. Omitting such mechanism isconsidered, however, because in certain embodiments the insert (2) canbe retained in the body by means of a thickened portion of the insertthat comes into contact with the walls of the body passage so that theinsert is forcibly inserted into the passage and is held there byfriction. In fact, the insertion trajectory of the insert into the bodyis sufficiently different from the orientation along which the forces onthe insert will be exerted that the insert may be retained in the bodywith no other specific means. Thus, upon being inserted into the body ofthe implant, the insert constitutes a means of retaining the implantbetween the spines, whether or not the insert itself has means for beingretained within the implant. Likewise, instead of a thickening, it ispossible for the insert to be retained within the body due to the factthat its curvature is so great compared to the dimensions of the passagethat it must be forcibly inserted in the passage and is retained thereby its own contact with the walls of the passage. A less flexible insertwould then be preferred to avoid having it be too easily dislodged fromthe passage by deforming under the effect of forces. Nevertheless, toensure good retention of the insert, various stop (i.e., retention)mechanisms including specific stop (i.e., retention) means or resourcesare also considered.

In certain embodiments, the stop mechanism includes at least oneinsertion stop (25) for the insert (2), located preferably on a backpart of the insert (2) (near the back lateral face of the implant) andincluding an abutment surface facing preferably the anterior end of theinsert to make contact with a complementary surface of the body (10)preferably facing the posterior end of the insert (2). The orientationof the abutment surfaces is not necessarily orthogonal to theanteroposterior direction of the insert, but it preferably will providestable abutment to retain the insert (2) and avoid having it penetratetoo far into the passage (15). The abutment surface of the body (10)will preferably be near the passage (15) to receive the insertion stop(25) of the insert (2), even inside the passage (15) if the insertionstop (25) of the insert is further forward than the posterior end of theinsert (2). Thus insertion stops (25) are shown in the illustrativeexamples in FIGS. 1A through 1C in the form of tabs arranged at theposterior end of the insert (2). These tabs (25) are preferably bentback toward the inside of the curve of the insert (2) to provide abetter abutment surface preventing the insert (2) from penetratingfarther into the passage. Additional examples of insertion stops (25)are shown in the illustrative examples of FIGS. 5A, 5C, 5E and 5G in theform of an embossment or thickening of the insert. Various shapes can beconsidered for this embossment and the triangular-section shape that canbe seen in particular in FIG. 5G is not limiting because it isunderstood that a correctly oriented abutment surface is sufficient tocarry out the function. Likewise, in the illustrative examples of FIGS.10A and 10B, the insertion stop (25) is obtained due to the fact thatthe insert (2) has a shoulder which will come into contact with the bodyat the entrance to the passage (around the passage). The possiblevariations for the shape of the insertion stop (25) can be understoodfrom these various examples.

In certain embodiments the stop mechanism preferably includes at leastone withdrawal stop (20), arranged to impede the withdrawal of theinsert (2), in order to avoid having the insert leave the passage (15)unintentionally. Such a withdrawal stop (20) preferably does not impedethe insertion of the insert (2) into the passage (15). In someembodiments, the withdrawal stop is preferably made up of at least oneflexible tab (20) arranged, firstly, to be able to move from its restposition during the insertion of the insert (2) into the passage, so asto allow the movement of the insert (2) and, secondly, to return to itsrest position so as to abut a complementary surface (122) when theinsert reaches its final position within the body (10). The flexible tabis preferably provided on the insert (2) and oriented substantially inthe direction of the posterior end of the insert (2), but it will benoted that it is also possible to provide at least one flexible tab onthe body (10) instead of on the insert (2) and the tab will then beoriented in the direction of the anterior end of the insert (2) whichwill then include an abutment surface (122) to receive the end of thetab, for example with a shoulder provided at an appropriate distancefrom the ends of the insert (2). The tab preferably moves in thedirection of the structure on which it is mounted (attached or built-in,in one piece or not) to allow the insertion of the insert. Preferably,it moves within a recess provided for the purpose so as not to extendout of the structure on which it is mounted. Thus for example, as can beseen in FIGS. 5A through 5D, the tab folds into a recess in the edges ofthe plate, so as not to project outside the width of the plate. Variouswithdrawal stop configurations, and in particular flexible tabs, arethus considered in the present invention. In certain embodiments, anexample of which is illustrated in FIGS. 5A and 5B, the flexible tab(20) is located on a lateral edge of the plate constituting the insert(2). In other embodiments, an example of which is illustrated in FIGS.5C and 5D, two flexible tabs (20) are located each on one lateral edgeto provide symmetrical locking of the insert (2). In other embodiments,an example of which is illustrated in FIGS. 5E through 5G, a flexibletab (20) is arranged on one of the faces of the insert. It is possiblemoreover to select a tab on a concave or a convex part, but the concavesurface is generally preferred to ensure better retention of the insert(2). Optionally, several withdrawal stops (20) can be provided on one orseveral faces and/or edges of the insert's plate and the body can beprovided with several complementary stop surfaces (122) for receivingthese withdrawal stops.

The use of a stop mechanism combining the insertion stop (25) and thewithdrawal stop (20) is preferred, provided on the insert (2) atpositions suited to simultaneous operation, so that the insert (2)engages the insertion stop and the withdrawal stop at the same time onceit is inserted far enough into the implant to extend to the desired partof the lateral faces of the spinous processes. Thus, the flexible tabsforming the withdrawal stop (20) of the insert (2) will preferably beoriented in the direction of the insertion stop (25).

In certain embodiments, the insert (2) can include at least one means ofretaining the insert, designed to receive a tool allowing a pull to beexerted on the insert (2) in order to disengage it from the passage(15), for example when it is desired to withdraw the implant. Forexample, as shown in the illustrative examples of tabs in FIGS. 1A, 1C,2A and 2C, a recess is provided on the tabs (25) constituting the stopto receive a tool. By inserting the end of a tool into this recess, theinsert can be pulled on to withdraw it. It will be noted that othergripping means than a recess can be provided, and a male structureinstead of a female structure in particular. In addition, these means ofgripping the insert can be provided on the stop (25) or at variousplaces on the insert, preferably accessible on the back lateral face ofthe implant, according to various possible embodiments. For example,other types of inserts (2) are shown in FIGS. 13A, 13B and 13C whichalso include such retention means, such as ring (26), at the posteriorend of the insert (2). This retention means (26), made up in thisexample of a cylindrical recess provided on at least part of the widthof the insert to allow good retention of the insert (2), can be used forremoval of the insert (2), but also during implantation of the insert tofacilitate the entry of the insert (2) into the passage, as detailed inthe present application.

As mentioned previously, in certain cases it is desirable to be able towithdraw the insert (2) and a gripping means can be provided forwithdrawal, but in the case where the insert also includes a withdrawalstop, as for example flexible tabs, a means for disengaging thewithdrawal stop is then provided. Flexible tabs (20) are particularlyadvantageous for that because they can be moved in order to allow theinsert to back down the passage. In the case where the flexible tab isso arranged that the withdrawal stop is accomplished within the passage,an access duct (120) to the flexible tab is provided in the body. On theother hand, in certain embodiments, the flexible tab (20) is arrangedoutside the passage (whether on the insert or on the body) and istherefore directly accessible to be disengaged from its complementarysurface in order to allow removal of the insert. It should be noted herethat the stop surface (122) arranged to receive (complementary to) theflexible tab (20) can be formed by the walls of the access conduit (120)or by a surface specifically provided elsewhere in or on the body (10)of the implant. For example, in FIGS. 8C and 12B are shown bytransparence the stop surface (122) which does not coincide with thewalls of the access conduit (120). It will be understood that the accessconduit allow one to press on the tab (20) but that the abutment of thelatter will occur at the surface (122) which is inside the passage shownin these figures. However, it will be understood that it is simplypossible that the access conduit or housing forms itself, by its walls,a stop surface that can accommodate the free end of the flexible tabwhich can then be directly operated to be disengaged. Indeed, forexample as shown in FIGS. 18A, 18B and 18C, and also on FIGS. 19A, 19Band 19C, the access recess or conduit (120) may be arranged so that atleast one of its walls forms the stop surface (122). Hence, the free end(the one used as a stop surface) of the flexible lug (20) can directlyabut a wall (122) of the conduit or other retainer structure disposed inor along the access conduit (120). One can thus directly access the freeend of the flexible lug (20) to disengage it from its stop (122).

Moreover, the complementary abutment surface (122) for receiving the tab(20) is preferably provided in the walls of the passage, but it can benear the passage (15), that is at the entry or the outlet of thepassage, as for example and preferably a surface at the entry to thepassage. The access duct (120) can then be an indentation running alongthe passage (15) and accessible at the entry to the passage. A stopmechanism located in the passage (15) is generally preferred, or atleast an indentation near the passage (15), to avoid having the flexibletab (20) disengage unintentionally, and an access duct (120) will thenpreferably be arranged in the body (10) as shown for example in FIGS. 4Athrough 4D, 6A through 6F, 7A through 7D or 8A through 8C. This accessduct (120), and hence the tab (20), as well as the surface complementaryto it, will preferably be arranged to be easily accessible, by adjustingtheir positions and/or their orientations so that the tab can beactuated, preferably from a lateral or posterior or oblique approach tothe vertebral column.

For the embodiments illustrated for example in FIGS. 1A and 1C, the body(10) includes a lower face (10 a) and an upper face (10 b). These upperand lower faces are arranged to come into contact with, respectively,the upper edge (E2) of the lower spinous process (EI) and the lower edge(E3) of the upper spinous process (ES), as can be seen in particular inFIGS. 17A through 17C. Thus, depending on the dimensions and possiblythe shape selected for the body (10), and particularly the height of thebody, that is the distance between its lower (10 a) and upper (10 b)faces, the interspinous space can be maintained or increased, forexample to restore it to a physiological value when it had been reducedto a pathological value. It is understood that these considerations ofupper and lower faces and of implant height are applicable to all theembodiments detailed in the present application. In these embodiments,contact of the adjacent edges (E2, E3) of the two spinous processes (EI,ES) with the upper (10 b) and lower (10 a) surfaces of the implantoccurs on at least a part of these surfaces (10 a, 10 b). The spacing ofthese two spinous processes (EI, ES) obtained by the insertion of theimplant between the adjacent edges (E2, E3) of the two spinous processesis therefore determined by the distance between these two parts wherecontact takes place. It will be noted that, in certain embodiments,particularly those where compression of the spinous processes isprovided for by a pivoting motion of the insert or pivoting of twoinserts relative to one another, or even pivoting of different parts andportions of the retainers (as detailed later in the present application,for example with reference to FIGS. 43A, 43B and 43C), contact with aspinous process can occur both on a part of one of the surfaces, lower(10 a) or upper (10 b), of the body (10) and on part of one of theconcave surfaces of the insert (2). Body dimensions (distance betweenthe lower and upper surfaces of the body) and an arrangement of theimplant (position of the insert passage and positioning of the insert inthe body) are then provided that allow the desired spacing between thespinous processes.

In certain embodiments, examples of which are illustrated in FIGS. 1Athrough 1C and 2A through 2C, the interspinous implant (1) includes twowings (11, 12) arranged on a single lateral face of the implant (1) soas to each lie along only one of the two spinous processes (EI, ES), onthe same lateral face (E4, E5) as the other wing. This implant includestwo passages (15) provided in the body (10) for the insertion of twoinserts (2) each projecting toward one of the spinous processes (EI, ES)to both lie along the same lateral face (E5, E4) which is opposite thatwhich the wings lie along. These two inserts (2) therefore constitutesaid at least one retainer of the implant, supplementing the two wings.The passages (15) are accessible for insertion of the inserts (2) in thesame lateral face as the wings (11, 12) so that the implantation betweenthe spinous processes (EI, ES) can be performed from a single one oftheir lateral faces (E4, E5). In these embodiments, the implant (1)preferably has substantially a T shape, the vertical branch of which isformed by the body (10), with the horizontal branches of the T beingmade up of two wings (11, 12) arranged on the same lateral face (10 c)of the implant (1) to lie along the same lateral faces (E4, E5) of thespinous processes (EI, ES). The two passages (15) being arranged toreceive the insert (2) on the same lateral face as the two wings, theyare preferably arranged in an indentation of this lateral face (10 c)between the two wings (11, 12), to allow for a stop (25) of each insert(2) remaining at the entry to the passages (15) not extend beyond thewidth of the body (10), as can be seen particularly in FIGS. 1C and 2C.In these embodiments, the inserts (2) preferably include at least oneplate of which at least a part is curved. Preferably, the insert (2) hasthe shape of a curved plate having a radius of curvature on at least itslongitudinal axis.

Preferably, one of the two passages is arranged to pass through a partof the body from a lateral face (10 c) toward the upper face (10 b) ofthe body (10) and the other passage is arranged to pass through a partof the body (10) from the same lateral face (10 c) toward the lower face(10 a).

The two passages (15) are preferably side by side, that is located adistance from one another along the Y direction, but they can bestacked, that is located a distance from one another along the Xdirection. If they are stacked, given the curvature of the insert (2),if it is desired that both inserts (2) be able to be inserted at thesame time (by a single manipulation, for example using an appropriateinstrument), they must be sufficiently separated depending on the radiusof curvature, while when they are side by side, the 2 inserts (2) can beinserted at the same time regardless of their curvature and of thespacing between the two passages (15). Nevertheless it is possible toinsert the two inserts (2) in succession without that resulting in toogreat an inconvenience, in particular thanks to the stability of theimplant provided by the first insert (2) which would have already beenput in place. In addition, as indicated previously, as the inserts (2)can be provided with a means of retention, it will be easy to insertthem, even in succession. It will also be noted that it is possible toprovide a single duct, for example with the two passages (15) for thesetwo inserts (2) forming a common duct separating into two divergentchannels to guide each of the inserts toward one of the two spines,whether the two passages are one above the other or side-by-side.Further, it is also possible to provide inserts with a curved plate thatis separated into two branches (e.g., 253, 254; FIG. 42B), at least on aposterior portion of the curved plate, such that the two inserts can benested inside one another and inserted at the same time. Thus, onebranch of each insert passes between the two branches of the otherinsert and the two inserts can follow their opposite trajectories at thesame time without interfering with one another. An example of such atwo-branched insert is described in more detail in the presentapplication, but only in certain embodiments where the two inserts arepivoting about a common hinge (a common articulation pin) shown in FIGS.42A, 42B and 42C. However, it will be understood here that it ispossible to provide two-branched inserts which are not assembled on acommon axis and which simply have two branches (253, 254) allowing themto be nested together so that they can be inserted at the same time. Inaddition, it will be understood from the detailed description hereafterof the inserts having a common hinge that it is possible to also usesuch inserts having a common hinge in implant embodiments such as thoseshown in FIGS. 1A through 1C and 2A through 2C. Preferably, the hingewill not extend beyond the two inserts so as to be able to penetrateinto the passage and the inserts will be provided with stop arrangements(preferably at least one withdrawal stop) to avoid having them come backout of the passage (15) in the implant. On the other hand, an insertionstop is not necessarily required because at least one wall of thepassage will provide a stop for the common hinge and/or the nesting ofthe inserts of the branches, thus making it possible to avoid having thelatter penetrate too deeply into the passages (15). In the case of twonested inserts without a common hinge, it is preferably provided thatthe two branches do not join at the posterior end of the inserts, toallow each of them to be pushed into the passage all the way withoutprojecting too far from the surface of the implant (this alsofacilitates the manufacture of the inserts since they would have to bein two parts to be able to be assembled by nesting them one in the otherif the branches of each of them were joined).

In certain embodiments where the body includes two passages (15) forreceiving two curved inserts (2) inserted in succession, the two inserts(2), and possibly the body (10) are designed so that the insertion stop(25) of a first insert (2) having a withdrawal stop (20) extend to thesecond insert (2) to constitute a withdrawal stop (20) for this secondinsert (2). The insertion stop (25) therefore makes it possible to stopthe insertion of the second insert but also extends to bear on a portionof the second insert (2). The first insert (2) which includes awithdrawal stop (20) preventing it from withdrawing from its passage,provides due to its insertion stop (25) a withdrawal stop preventing thesecond insert from withdrawing from its passage (15). In addition, incertain of these embodiments, the withdrawal stop (20) of the firstinsert is designed to bear on the second insert (instead of bearing onthe body of the implant).

In certain embodiments, in particular those where the implant (1)includes two wings on the same lateral face, the body preferably, butwithout limitation, includes on its anterior part (intended to beinserted first), at least one chamfer (105) to facilitate its insertioninto the interspinous space (particularly through the interspinousligament). For example, as can be seen particularly in FIGS. 1A, 2A, 1Cand 2C, the body can be provided with chamfers (105) at the anterior endof the upper and lower faces, but also of the faces arranged in thedirections forward and rearward of the patient. Thus, the lateralanterior part of the body (referred to the direction of insertion) hassmaller dimensions than the rest of the body to facilitate its insertionbetween the upper edge (E2) of the lower spinous process (EI) and thelower edge (E3) of the upper spinous process (ES).

In certain embodiments, an example of which is illustrated in FIGS. 3Athrough 3C, the body (10) includes two wings (11, 12) arranged on thesame back lateral face (10 c) of the implant (1) to lie each along oneof the two spinous processes, but on the same back lateral face (E4,E5), and a third wing (17) arranged on the front lateral face (10 d)(the opposite face), to lie along the front lateral face (E5, E4) of afirst of the two spinous processes (EI, ES). Said at least one retainercan then include a curved insert supplementing these three wings in thefunction of retaining the implant. Indeed, a passage (15) is thenprovided in the body (10) for the insertion of an insert (2) projectingtoward the second spinous process (ES, E1), so that this insert (2) liesalong the same lateral face (E5, E4) as the third wing (17) (but f thesecond spinous process while the third wing lies along the first spinousprocess). This passage (15) is accessible for insertion of the insert(2) on the back lateral face (10 c) of the implant equipped with thethree wings (11, 12, 17), so that the implantation between the spinousprocesses (EI, ES) can be performable from a single one of their lateralfaces (E4, E5). In these embodiments, a chamfer is preferably arrangedon the upper (10 b) or lower (10 a) face equipped with a single wing (onthe lateral face having only one wing), so as to facilitate theinsertion of the implant into the interspinous space. In addition, theseembodiments are better suited to cases where it is desired to allow acertain amount of lateral play to the implant thanks to sufficientspacing between one of the wings (12) and the third wing (17). It isthen possible to have a spacing between the wing (11) and the insert (2)which allows or does not allow play because the insertion of the insert(2) imposes less constraint on the implantation, while the insertion ofthe upper or lower part of the implant (depending on the orientationgiven) equipped with the third wing is more awkward, particularly if theheight of the implant is selected so as to restore an interspinous spaceheight greater than the value that it has before the implantation. It istherefore understood that the embodiments where said at least oneretainer include(s) two curved inserts are preferred over those wherethe implant includes three wings and where the retainer includes acurved insert, particularly if no other retainer arrangement supplementsthis curved insert. Indeed, here the implant must, in order to be easyto implant, have a space between the third wing and its counterpartwhich does not ensure optimal support along the Z axis. Otherarrangements, or at least combining this embodiment with otherretainers, will therefore be preferred, as for example a ligament (L) ora bone anchorage means, the advantages whereof are detailed in thefollowing. Likewise, rather than the embodiments whose body has threewings, the embodiments described in the following will also bepreferred, in which the body has only two wings, of which one wing liesalong a lateral face of a spine and the other lies along the oppositeface of the other spine.

In certain embodiments, examples of which are illustrated in FIGS. 4Athrough 4D, 6A through 6F, 7A through 7D, 8A through 8C, 9A and 9B, 10Aand 10C, 11A and 11B, 12A through 12C, 13A through 13C, 14A, 15A, 15Band 17A through 17C, the body includes two wings (11, 12) each arrangedon one lateral face (E4, E5) opposite the other wing (12, 11) and eachprojecting toward one of the two spinous processes, so that the wingseach lie along a spinous process (EI, ES) but on opposite lateral faces(E4, E5). Thus, a first wing lies along a first spinous process on onelateral face and another wing lies along a second spinous process, onthe opposite lateral face. These are particularly advantageousembodiments, particularly due to their ease of implantation and thesimplicity of their shape, and they are used with various types ofretainer as detailed in the present description. In certain of theseparticularly advantageous embodiments, it is possible to use only asingle insert (2) as a retainer. This has the advantages of reducing thenumber of parts (which reduces costs and the number of parts which mightpossibly migrate within the interspinous space or its edges),facilitating the manufacture of the body (which has only one passageinstead of two) and being able, for the same body size, to provide alarger insert (particularly in thickness) to as to be more robust (thanin the case where two inserts have to be run into a body). Further, thefact that the two wings are on opposite faces of the insert allow onewing to be on the face opposite to that by which the vertebral column ispossibly approached for implantation, which can be an advantage in termsof the stability of the implant, but the implant is mainly easier toimplant even if the spinous processes must be spread apart. Indeed, theimplant can be used to restore sufficient interspinous spacing asexplained previously. In this case, the fact that the insert has its twowings on opposite faces means that one wing is inserted first to makethe body pivot until the two wings lie along the spinous processes.Thus, in the case of a very tight interspinous space, the body and thefirst inserted wing can serve as spreaders for separating the twospinous processes and forcing the insertion of the body between the twospinous processes. In the three-wings embodiments, this passage will beeven more difficult and in the two-wings embodiments where the two wingsare on the same face, it is the body which is inserted first and thechamfer, if any, at the front will not necessarily be sufficient toallow the front of the body to be inserted and to progressively spreadapart the two spinous processes. However, if the two spinous processesare closer from each other than the height of the body at thesechamfers, these embodiments will prove especially effective.

In the case of these implants with two opposite wings wherein theretainer includes an insert, this insert (2) includes two curves ofopposite orientations. This insert (2) is then generally ofsubstantially sigmoidal shape due to the fact that its plate includes atleast two radii of curvature of opposite orientations, so that two facesof the plate each have a concave part and a convex part. The passage(15) and the insert (2) are then arranged so that, when the insert (2)is lodged in the passage (15), at least a part of said convex parts ofthe two faces of the insert (2) each lies along at least a part of thespinous processes (EI, ES), on lateral faces (E5, E4) opposite to thosealong which the wings lie (11, 12). The insert (2) is then stillinserted along a single back lateral face (10 c) of the implant (1)while still obtaining good retention on the two lateral faces (E4, E5)of the spinous processes (EI, ES). The insertion of the insert istherefore performed along an axis that is more parallel to the vertebralcolumn than in the other embodiments, but generally without therebycausing a problem of bulk since the axis lies substantially along alateral face of the spinous processes. The illustrative examples inFIGS. 12A, 12B and 12C illustrate the shape of the passage (15) in whichthe sigmoidal-shaped insert (2) is inserted and shows examples ofanchorage means (150, 151) arranged for grasping the body (10) using aninstrument as explained in the present application.

In certain embodiments, the insert (2), whether having a single curve ortwo curves of opposite orientation as described in the presentapplication, has at least one rib to stiffen it. This rib (not shown) ispreferably on at least a portion of the convex face of the insert (2),such that it is not set facing or in contact with lateral faces of thespinous processes. In such embodiments of the insert, the passage (15)for the insert (2) in the body (10) of the implant includes at least onegroove arranged to receive this rib on the insert (2). A stiffenedinsert (2) is thus obtained which is stably held within the body due tothe complementary shape of its rib and the groove present in one of thewalls of the passage in the body.

In certain of these embodiments having two opposed wings and a sigmoidalinsert, the implant then includes at least one ridge (13, 14) on atleast one of its lower (10 a) and upper (10 b) faces, preferably near orat the junction with the lateral faces not having wings (11, 12). Such aridge (13, 14) impedes the implant (1) from disengaging from the spacebetween the adjacent edges (E2, E3) of the two spinous processes (EI,ES). The ridge can have the shape of a shoulder, preferably slightlyrounded, or any other shape giving greater height to the implant at theshoulder than between the lower and upper faces, so that the implantwill be impeded by the ridge if it were to slip between the two spinousprocesses before the insertion of the insert (2). The ridge (13, 14) ispreferably chamfered or rounded on its part located toward a lateralface of the implant (1), so as to facilitate the insertion of the body(10) between the adjacent edges (E2, E3) of the two spinous processes(EI, ES). It will be noted that such a ridge can also be provided in theembodiments where the wings are on the same lateral face and examples ofwhich are shown in FIGS. 1A through 1C and 2A through 2C, even thoughthese examples do not show such a ridge. However, a ridge willpreferably be provided on only one of the upper (10 b) or lower (10 a)faces so as not to hinder the insertion of the implant (1). A possiblechamfer (105) on the lower (10 a) or upper (10 b) face other than thatprovided with a ridge will then facilitate the insertion of the implant(particularly by allow it to be slightly tilted to allow the ridge topass into the interspinous space). On the other hand, in embodimentsequipped with three wings, it will be preferable not to provide a ridgeon the upper (10 b) or lower (10 a) face provided with only a singlewing, so as not to impede the insertion of the implant (1) into theinterspinous space.

In certain particularly advantageous embodiments, an example of which isillustrated in FIG. 9A, the body (10) includes, at least on its upper(10 b) and lower (10 a) faces in contact with the adjacent edges (E2,E3) of the two spinous processes (EI, ES), at least one material (8)favoring bone growth to allow the fusion of the upper (ES) and lower(EI) spinous processes. The bone-growth-favoring material (8) can forinstance be bone, such as a graft or any other substitute. Preferably,the bone-growth-favoring material (8) is not simply arranged on theupper and lower faces of the body, but instead is arranged so as toprovide continuity allowing fusion of the two spinous processes. Thusthe body preferably has a central hollow or duct, substantiallycylindrical or honeycombed, for example, running across the body (10)from side to side between the upper and lower faces (10 a, 10 b) incontact with the adjacent edges (E2, E3) of the two spinous processes(EI, ES). This duct filled with bone-growth-favoring material (8) thenprovides continuity allowing bone growth through the implant and allowsthe upper (ES) and lower (EI) spinous processes to fuse together. As thebone growth trajectory through the body crosses the insert (2), as canbe seen particularly in FIG. 9A, a passage (not shown) will preferablybe provided in the insert to allow bone growth through the insert and/orthe duct will be larger than the insert (2) and the passage (15) toprovide room on either side of the passage so that bone growth canoccur, respectively, through and/or around the insert. For example, itcan be arranged that the duct that crosses the body between its upperand lower faces receives bone graft material or a substitute to allowthe bone tissue of the spinous processes to grow through the implant,for example by inserting the insert through the graft or substitute.Preferably, these embodiments providing for the addition of abone-growth-favoring material (8) will use means for bone anchorage ofthe wings and/or the insert into the spinous processes, as detailed inthe present application, so as to immobilize the spinous processes andthus facilitate spinal fusion.

In certain particularly advantageous embodiments, an example of which isillustrated in FIG. 9B, the implant includes at least one cushion (6),which may be made of various types of cushioning, (dampening, flexible)material (6), on at least one of its upper (10 b) and lower (10 a) facesin contact with the adjacent edges (E2, E3) of the two spinous processes(EI, ES), so as to cushion the longitudinal (vertical) motions of thedorsal spinous processes (EI, ES). Generally, fusion of the spinousprocesses is accompanied by fusion of the vertebral bodies (for examplewith an interbody cage in addition to the interspinous implant) and/orsometimes the joints (articular processes). All embodiments describedare preferably designed to stabilize the movement of spinous process,whether for purposes of fusing or not. The embodiments withdampening/cushioning and/or play are usually aiming at a flexible andcontrolled maintenance (that is to say, do not impose excessiveconstraints on the spinous processes), but are not exclusive fromembodiments allowing a fusion (by bone anchor and/or bone growthmaterial). Thus, in the embodiments with a damping/cushioning and/orplay, one might want a mobility or a damping, for example with thedamping material (6) to facilitate the implementation, while providing alock with bone anchorage resources though. Thus, for example, theflexible material (6) may help compress the implant during installation,waiting to fix the compressed ensemble by means of anchoring resources.This flexible material (6) therefore generally offers a flexibleinterface between the implant and the spinous processes, allowing theimplant to be more readily welcomed into the interspinous space.

In certain particularly advantageous embodiments, the implant (1) issuited to multi-level surgery, that is to the implantation of severalimplants between several consecutive spinous processes, each within aninterspinous space. For example, in certain embodiments, at least one ofthe wings (11, 12) and/or at least one insert (2) is (are) arranged withshapes and/or dimensions designed so that two implants (1) can beimplanted in at least two consecutive interspinous spaces of threeadjacent vertebrae, with or without overlap of the wings (11, 12) or theinserts (2), but preferably without any overlap so as to avoid areciprocal damage of the insert and wings. Thus for example, in variousembodiments, the length of the insert (2) or inserts (2) can be arrangedto extend farther than, less far than, or as far as the wings (11, 12)extend along the lateral faces (E4, E5) of the spinous processes (EI,ES). For example in the illustration in FIG. 1C, the two inserts (2)extend farther than the wings (along the longitudinal X axis of thevertebral column), while in the illustration in FIG. 2C the inserts donot extend farther than the wings. It will be understood that with aconfiguration such as that in FIG. 1C, by implanting, firstly, in afirst interspinous space an implant such as that of FIG. 1C through alateral face, according to the orientation shown in FIG. 1C andsecondly, in an interspinous space adjacent to the first, a secondimplant with the same configuration, but via the opposite lateral face(hence with an orientation that is inverted with respect to that of FIG.1C), inasmuch as the dimensions of the wings and the inserts arecorrectly matched to those of the lateral faces of the spinousprocesses, a succession of two implants is obtained which do not overlapand which are therefore suited to this multi-level surgery, while stillaffording good retention around the two consecutive interspinous spaces.Thus, each of the interspinous spaces will receive an implant from alateral face opposite the one from which the implants of adjacentinter-spinous spaces will have been inserted, forcing to make incisionson both sides on the spinous process, but for different inter-spinousimplants. Moreover, the absence of overlap can be obtained withoutreducing the length of the wings (11, 12). For example, the wings (11,12) and the inserts (2) can have shapes arranged so as to be mutuallycomplementary so that the wings and/or inserts of two implants can bearranged about the same dorsal spinous process (EI, ES). Theillustrative examples in FIGS. 13 a, 13 b and 13 c show for example twoidentical interspinous implants having complementarities of shape formulti-level surgery. In these examples, the lower part of a firstimplant (1) and the upper part of a second implant (1) are arranged tosurround in a complementary manner the same dorsal spine (EI, ES). Inthis example, the upper end of a wing of the second implant (1) (on thefront lateral face) has an indentation a notch or a cutting, for examplein a U shape, in the sagittal plane, capable of receiving a lower end ofthe sigmoid insert (2) of the first implant (1). Moreover, a lower endof a wing (12) of the first implant (1) has (on the back lateral face) acutaway giving for example this end a substantially L-shaped curve inthe sagittal plane, capable of receiving the upper end of thecomplementarily-shaped insert (2) of the second implant (2), provided inparticular with a retention means (26) deployed as a ring in thisexample. It is understood from these illustrative examples that implantscan be provided that are intended to be implanted in the samemediolateral direction or in opposite directions, with male or femaleshapes at the ends of their wings (11, 12) and inserts (2) to make itpossible to receive the ends of the wings and inserts of another implantimplanted in an adjacent interspinous space. Likewise, in theillustrative example shown in FIGS. 10A through 11A, the sigmoid insert(2) has an indentation (or a notch or a cut) at one end, splitting thecurved plate into two branches (22, 23), giving the insert a Y shape. Inthis example, the wings are not represented as being complementary tothis type of insert, but it is possible to provide a complementaryarrangement to allow multi-level surgery. However, this example is shownhere rather for illustrating another aspect relating to bone anchoragein the spinous processes.

Indeed, in certain particularly advantageous embodiments, usedparticularly when fusion of the two spinous processes (EI, ES) isdesired, or at least when a further stabilization is desired, theretainer of the implant includes bone anchorage means (3, 111, 121, 221,7, 28) arranged so as to anchor the implant in the spinous processes.These bone anchorage means favor the retention of the implant relativeto the spinous processes, but also allow the spinous processes to beheld relative to one another, which provides supplementary stabilization(and even permits fusion of the two spinous processes). These anchoragemeans make it possible to anchor the implant, for example at the levelof the wings (11, 12) and/or the inserts (2), in at least one of thelateral faces (E4, E5) of at least one of the spinous processes (EI,ES). For example, in certain embodiments, at least one wing (11, 12) ofthe implant (1) includes at least one point (111, 121) arranged so as toanchor itself in the lateral face (E4, E5) of the spinous process (EI,ES) along which said wing lies (11, 12). An example is illustrated inFIGS. 2A through 2C, where points (111, 121) on the wings (11, 12) arearranged so as to anchor themselves in the lateral face (E4, E5) of thedorsal spine (EI, ES) along which the two wings lie (11, 12). In otherembodiments, the sigmoidal insert (2) includes, on at least one of itsconcave parts, at least one point (221) arranged to anchor itself in thelateral face (E4, E5) of the spinous process (EI, ES) along which thisconvex part lies. An example is illustrated in FIGS. 4C and 4D; a point(221) is present near the rear end (posterior, in the insertiondirection) of the insert (2). This point of the insert (2) is preferablycurved in the direction of the anterior end of the insert (2), so as tomore easily anchor itself in the lateral face of the spinous processduring placement of the insert (2) in the body (10). The end of theinsert (2) opposite the one equipped with this point (221) is insertedfirst into the passage (15). This point (221) can be a fixed pointplaced on the concave part of one of the faces of the insert (2),preferably close to or at the posterior end. The point (221) can also bea point pivotably mounted on the insert (2) so that it can be foldedalong one face of the insert (2) or unfolded in the direction of thespinous process. The pivoting point can then be mounted on the convexface, but it will then be offset so as to be anchor in osseous tissuebeyond the end of the insert and its actuation will have to be carriedout during insertion to orient it so that it penetrates into the spinousprocess.

In other embodiments, such a pivoting bone anchorage means can bemounted on the convex face or on the lateral edges of the insert (2),for example by extending beyond the posterior end of the insert (2), tobe able to be applied to the spinous process, particularly after fullinsertion of the insert (2). For example, in the examples of FIGS. 7Athrough 7D, the posterior end of the insert (2) includes at least onepivoting hook (28). Likewise, the lower end of at least one of the wingscan include at least one pivoting hook (28), in particular a series ofpivoting hooks in these examples. It will be understood that one or morehooks can be arranged on each wing or insert. Bone anchorage means forthe inserts, however, are generally only possible for the posterior endsof the inserts, and preferably only for sigmoidal inserts. Pivotinganchorage means are preferably associated with actuating means arrangeto allow them to be pivoted so as to anchor them in the spinousprocesses. For example, in FIGS. 7A through 7D, the hooks (28) areassembled integrally with a pivot axis rotatably mounted in the insertand/or the wing and provided with an actuation means (280) having inthis example a hexagonal (or generally polygonal) head able to beactuated by a tool to pivot the hook(s) (28). The shape of the hooks(28), like that of the points (221) of the insert (2), will preferablybe optimized for penetration into bone, depending on the axis ofimplantation (the axis of rotation of the hook and the pivot axis of theinsert in the body, respectively, particularly in the case of thesigmoidal insert the insertion of which can be performed along asigmoidal trajectory with several consecutive pivot motions).

In certain embodiments, the interspinous implant comprises at least oneretainer including at least one bone anchor or bone anchoring resources(3, 111, 121, 221, 7, 28), as previously mentioned. One may considerthat the implant (1) comprises these resources (3, 111, 121, 221, 7, 28)or that these resources are independent, in particular in someembodiments of the latter in which they can be used with other types ofinterspinous implants. In fact, the bone anchoring resources detailed inthe present application may be formed directly on the implant and/or theinsert, but can also form a distinct device allowing to anchor theimplant and/or the insert into a spinous process.

In certain embodiments, at least one of the wings (11, 12) and/or atleast one insert (2) includes at least one passage such as a hole (131,231, 123, 232) or a slit arranged to receive a bone anchor (3), as forexample at least one pin (31, 32) of at least one bone anchorage device(3). The bone anchorage resources comprise preferably at least one pin.The pin preferably has a pointed end to be planted in the lateral faceof a spinous process. In some embodiments, the bone anchoring resourcescomprise attachment resources for their attachment to the implant (1)and/or the insert (2), the latter comprising complementary resources forallowing the attachment of the bone anchoring resources thereon. Forexample, the pin can include at least one threaded portion,complementary to a tapped thread in the hole in the wing or insert, toallow screwing. A pin provided with a head that allows screwing along anaxis substantially perpendicular to that of the pin will then bepreferred, as for example a hexagonal head. In other embodiments, thepins are not threaded. For example, in the examples in FIGS. 6C and 6D,a point (121) is present near the posterior end of the insert (2) whilethe lower wing (12) is anchored in the lower spinous process using ascrew. This screw runs through a hole in the wing, which preferably hasa tapped thread complementary to the thread of the screw which includesa head with actuation means such as a polygonal shape or socket. Theinsert (2) shown in the example in FIGS. 5A and 5B can be used in animplant as shown in FIGS. 6E and 6F, because this insert includes anopening designed to allow passage of a bone anchorage means made up of asmall anchor (7) which is driven into the lateral face of the spinousprocess. This anchor is preferably curved to facilitate its implantationfrom the implantation approach of the implant and includes preferably aninsertion stop (72) and a withdrawal stop (71) similar to those detailedfor the implant in the present application. This anchor is preferablymade up of a metal plate, preferably sharpened at its anterior end tofacilitate its penetration into the bone, and preferably includes anindentation at its anterior end for the same reason. This anchor thushas resources for attachment to the insert (2), formed by the insertionstop (72) and withdrawal stop (71). In other embodiments, theseresources for attachment of the bone anchorage resources may be formedby a latch (35), such as a flexible leg provided with a tooth arrangedto be clipped onto a shoulder of the implant and/or insert, such as inthe illustrative and not restrictive FIGS. 19A, 19B and 19C. It will beunderstood from the various examples that various types of attachmentresources are contemplated for the bone anchorage resources, inparticular when the latter are formed by a device distinct from theimplant and/or the insert. It will be noted that in the case ofresources provided with a tooth clipped into the implant and/or theinsert, a housing may be provided to allow access for disengaging thetooth from the shoulder, so as to enable withdrawal of the bone anchor.The access recess can be provided in the anchoring device and/or theimplant and/or insert on which the attachment resources allow to attachthe bone anchor.

In certain embodiments of the bone anchoring resources (3), two pins(31, 32), preferably pointed or sharp, are connected, at the endsopposite the pointed ones, by a transverse bar (30), substantially(i.e., at least approximately) perpendicular to the axis of the pins(31, 32), so as to form a bone anchoring device (3) substantially havingthe shape of a staple. In certain embodiments, the staple is designed sothat its two prongs (31, 32) penetrate the spinous processes throughholes in the implant. However, depending on the dimensions of the staplecompared with those of the implant, the staple can be designed topenetrate into the spinous processes beyond the wings of the implant. Inthis case, means of attaching the staple to the implant will preferablybe provided so that the staple constitutes a retainer for the spinousprocesses. It will be noted that this type of bone anchorage device (3)can be used with various types of implants described in the presentapplication, particularly implants including a means of retaining theimplant other than an insert, as for example a ligament (L), acomplementary body, etc. In the examples of FIGS. 8A through 8C, theinterspinous implant (1) has two wings (11, 12) having two holes (231,232) and an insert of sigmoidal shape (2) having two holes (123, 131). Abone anchorage device (3) is then provided, with two points (31, 32),designed to first pass through the hole (231) in the insert (2) and thehole (123) in the wing (12), then, secondly, to pass through the twodorsal spines (EI, ES) and finally, thirdly, to embed itself in the hole(131) in the wing (11) and the hole (232) in the insert (2) on the otherside of the spinous process. The bone anchorage device (3) including apin or a bar (30) between the two anchorage points or pins (31, 32) canpreferably have a pin or a bar (30) having at least one plane surface onthe face where the points originate, and preferably the insert willinclude around the hole (231), for one of the points, at least one planepart to receive the plane part of the bone anchorage means, which allowsthe anchorage means to conform well to the shape of the implant, as canbe seen particularly on FIG. 8C.

In such cases of bone anchorage means (3) forming a kind of staple,which provides means for retaining the spinous processes and thussupplements the implant's retainer formed by an insert (2), it ispossible to provide an insert (2) arranged so as to be placed during theanchoring of said staple. For example, the sigmoidal insert (2) caninclude, at one of its ends an indentation, a notch, a cutting, or asplit separating the curved plate into two branches (22, 23) andincluding an abutment surface intended to receive a transverse bar (30)of a bone anchorage device (3) including two pins (31, 32) perpendicularto said bar (30), the anchorage device (3) being arranged so that saidbar (30) bears on the abutment surface of the indentation in the insert(2) and causes the insert to enter the through passage (15) of theimplant (1) when the pins (31, 32) penetrate a lateral surface (E4, E5)of the vertebral spinous processes (EI, ES). While one of the pins (31,32) passes between the branches (22, 23) of the insert for penetratinginto one of the spinous processes, the other pin penetrates into theother spinous process, either through a hole (123, 131) in one wing (11,12) of the implant as shown in FIGS. 11A and 11B for example, ordirectly as shown on FIGS. 18A, 18B and 18C and on FIGS. 19A, 19B and19C for example. The bottom of the split thus provides an abutmentsurface for the bone anchorage means. This surface will preferably becurved (convex) in the sense of a portion of the outside of a cylinder,to facilitate the pivoting of the insert with respect to the boneanchorage means, particularly in the preferred case where thoseanchorage means have a plane face for better contact with the implantassembly once assembled, as described with reference to FIG. 8C and ascan also be seen here in FIG. 11B.

Other illustrative examples of insert (2) arranged to be inserted duringthe anchoring of bone anchorage resources (3) forming a kind of stapleare shown in FIGS. 18A, 18B and 18C and 19A, 19B and 19C. In theillustrative and nonlimiting examples of FIGS. 18A, 18B and 18C, theimplant (1) and insert (2) represented are adapted to a multi-levelsurgery as detailed in this application. Of course, the same mechanismof simultaneous anchoring and insertion of the insert can nonetheless beprovided with implants and inserts of other shapes. In the illustrativeexamples shown in FIGS. 18A, 18B and 18C, the bone anchorage resourcesand the insert are also arranged for the insertion of the insert duringthe anchorage of the anchoring resources. The insert, with anindentation separating the plate into two branches, comprises aconnection (27) which links the two branches and protrudes out of theplane of these two branches. This connection keeps the bone anchoringdevice in place once implanted and thus forms an attachment resource asdetailed above, but also facilitates the handling of the ensemble duringthe insertion of the insert and the bone anchoring. Indeed, the boneanchoring device (3) is introduced between the two branches of theinsert (2) and retained relative to the insert thanks to this connection(27), as particularly shown in FIG. 18B. Moreover, in some embodiments,the implant is provided with at least one housing, recess, groove, slot,or other accommodation for at least a portion of at least one boneanchor. For example, in FIG. 18C, we see that the implant (1) has agroove on its lateral side receiving the bone anchoring device. Thegroove is sized and located so as to accommodate the crossbar (30) ofthe bone anchoring device (3). This housing will prevent the anchoringdevice from protruding too much outside the body (10) of the implant andthus present an overly large encumbrance. In the illustrative examplesshown in FIGS. 19A, 19B and 19C, the bone anchorage resources are alsoformed by a staple (3), preferably with the crossbar (30) received in alongitudinal groove on a side face of implant (1). In this example, thecrossbar (30) is provided with an attachment resource formed by a latch(35) comprising a flexible leg provided with a tooth designed to beclipped onto a shoulder (135) present in the body of the implant (1). Inthis example, the shoulder (135) is formed by the intersection betweenthe prehension housing (150) of the body and the side groove receivingthe staple. Other arrangements can of course be provided but the latteris particularly advantageous in terms of space since it allows thecombination of two means (the lateral groove and the gripping housing)to provide a further synergistic technical effect, obtained by theintersection of both resources.

In some embodiments of the bone anchorage resources, especially whenthey contain at least one sharp (pointed) pin or tip, the latter mayinclude teeth, detents, notches, protrusions, or any variations of shapeadapted to oppose the removal of this pin once planted in the bone.Illustrative and non-limiting examples of such shape variations arerepresented for the sharp ends of the pins (31, 32) of bone anchors (3)in FIGS. 18A, 18B, 18C and FIGS. 19A, 19B and 19C.

In some embodiments of the bone anchorage resources distinct from theimplant and/or insert, these bone anchorage resources comprise at leastone grip or other grasping structure (36) to facilitate their removal.This grip or other grasping structure (36) of the bone anchorageresources (3) may include a housing, a projection or shape variation ona surface of the bone anchorage resources, to be gripped or held, forexample with the end of a tool for removal of bone anchorage resources.In the example shown in illustrative and non-limiting FIGS. 18A, 18B and18C, a housing (36) present on the crossbar (30) allows the introductionof a tool to pull on the bone anchorage resources.

In certain embodiments, said at least one retainer of the implantincludes anti-slip means (29) allowing to retain the spinous processes,particularly on at least one part of at least one of the wings and/or onat least one part of at least one insert, to limit the motions of theimplant (2) with respect to the spinous processes and conversely. Forexample, in FIGS. 6A and 6B, the wings (11, 12) and the insert (2C) havetoothed surfaces or notches (29) to inhibit motion of the dorsal spines(EI, ES) relative to the implant (1) or conversely. When the insert (2)includes such notches (29) and/or points (221) near its anterior end, orat least on the portion which must pass through the body (10) of theimplant, the passage (15) in the body (10) of the implant preferably isdesigned for the passage of these notches (29) and/or points (221).Thus, in certain embodiments, the passage (15) can be enlarged to allowthe notches (29) and/or points (221) to pass. Likewise, in otherembodiments, the entire width (i.e. dimension along the Y axis) of theinsert is not occupied by such notches (29) and/or points (221), asshown for example in the figures of plates 36, 37, 38, 39 and 40. Thepassage (15) can then include grooves (155) for the passage of thenotches (29) and/or points (221) instead of having to be enlarged overits entire height.

In some embodiments, hooking resources (4, 24) for hooking the spinousprocesses (EI, ES) are designed to improve the retention of the implantbetween two spinous processes, by hooking at least one of the spinousprocesses. In some of these embodiments, hooking resources (4, 24) aredesigned to hook the two adjacent spinous processes between which theimplant is placed and, then, they provide a function of retaining thespinous processes, in addition to the function of retaining the implant.Here, “hooking resources” is used to designate structures which arearranged to extend so as to hook along at least part of an edge of aspinous process which is opposite to the edge of the spinous processagainst which the body (10) of the implant is disposed. It willnevertheless be noted that so-called “laminar” hooks are known in thefield of vertebral column implants, which are arranged so as to hookaround at least part of the edge of the vertebral lamina (that is theportion extending between the spinous process and the transverseprocess). It will therefore be understood that the hooking resourcesdescribed here can generally be arranged to hook onto at least part ofan edge of a spine and/or of a vertebral lamina. Double hooks can alsobe provided, for example with one branch that hooks onto an edge of aspine and another branch that hooks an edge of the lamina adjacent tothis edge of the spinous process. This set of concepts is simplydesignated here by the term “hooking resources.” Thus, for example, withan implant (1) inserted between the upper edge (E2) of a lower spinousprocess (EI) and the lower edge (E3) of an upper spinous process (ES),the spinous process's hooking resources (4, 24) are arranged to hookover the upper edge (E2) of the upper spinous process (ES) and/or thelower edge (E3) of the lower spinous process (EI). The simplifying termof “opposite edge” is used here to refer to the edge of a spinousprocess which is opposite the edge (E2, E3) which is in contact with thebody (10) of the implant. The term hooking is used to denote the factthat these resources extend partially around an edge, like a hook thatis hung on this edge. It will be understood that this hook shape is notlimiting and that various shapes can be provided, as long as it allowshanging or retaining the implant on a portion of said opposite edge.Similarly, the extent of this hook, that is to say the portion to whichit extends on the lateral face opposite the one from which it isimplanted, may vary, preferably in a range allowing reliable holding ofthe implant. Preferably, these spinous hooking resources (4, 24) arearranged to be used from one side face of the spinous process, as mostof the elements detailed in this application. These hooking resources(4, 24) allow, by extending to the opposite edge of two adjacent spinousprocesses, to limit or prevent the spinous processes from spreadingapart, for example beyond the value at which they are maintained by thebody (10) of the implant (1). Indeed, the implant is interposed betweentwo adjacent edges and can impose a minimum distance between two edgesof the two spinous processes, but these spinous processes may deviatefrom each other (spread apart), except in the case of bone anchoringresources designed for anchoring in both spinous processes. Thus, thesespinous hooking resources (4, 24) can also maintain a maximumseparation, by preventing the spinous processes from departing from eachother, as do bone anchoring resources, but with the additional benefitof limiting the risk of injury to bones and of reducing the risk ofdegradation of the binding obtained. Another potential advantage ofhooking resources (4, 24) is the variable setting of maximum separationobtained in some embodiments detailed in this application. In addition,since not all the spinous processes have the same “height” or “length”(that is to say the same dimension along the X axis), it is desirable toprovide hooking resources (4, 24) with adjustable size or to providevarious sizes of hooking resources (4, 24) in order to be able to hookthe various spinous processes of the rachis.

In some embodiments, these hooking resources (4, 24) are formed on theimplant (1) itself and/or the insert (2), but preferably only on oneside and arranged to extend at least partially around the opposite edgeof at least one of the spinous processes. Note that it is possible tocombine bone anchoring resources on one spinous process with hookingresources on the other spinous process, for example as shown in FIGS.20A and 20B, but also that both resources (hooking and anchoring) can becombined on a single spinous process or even that hooking or anchoringresources can be used on both spinous processes (EI, ES). These variousresources are not necessarily exclusive from each other, although it'sgenerally preferred that a spinous process is retained by only one ofthese resources. In addition, in the case where bone anchoring resourcesfor a spinous process are combined with hooking resources (4, 24) forthe other spine, the anchoring resources will preferably be chosen onthe wing of the body that is on the side through which the spinousprocesses are accessed to, while the hooking resources (4, 24) will beon the side of the implant that is not equipped with wing (on the sameside face of access), so as to avoid providing various sizes of implants(1) including hooking resources (4, 24). One advantage is then to beable to have the same type of implant (1) for use with various hookingresources (4, 24) of different sizes (to be adapted according to thesize of the spinous processes). This is especially true when the hookingresources (4, 24) are formed on the insert (2), especially the sigmoidinsert. However, in some embodiments, the position of the hookingresources (4, 24) can be adjusted as detailed below and this problem ofthe size of the spinous processes can be overcome. For example, ahook-shaped extension (24) can be attached to a wing of the body of theimplant (1) at varying positions so that they can adapt to differentsizes of spinous processes. In general, the hooking resources (4, 24)comprise at least one hook (24) which can be formed by a portion of theimplant or of the insert, but which can also be separate and attached tothe implant or the insert, for example through an attachment structure.One can for example choose for the first spinous process a first hookattached to the implant or the insert, and for the second spinousprocess a second hook attached to the implant.

In some of these embodiments having hooking means (4, 24) formed on theimplant (1) and/or insert (2), these hooking resources (4, 24) arepivotally mounted on the implant and/or the insert. Thus, for example asshown in FIGS. 20A and 20B illustrating, without limitation, those twoaspects on the same device (i.e., the aspect of combining anchoring andhooking resources and the aspect of pivoting hooking resources), animplant equipped with bone anchorage resources, for example, hooks (28)pivoting on one of its wings (12) is associated with a sigmoid insert(2) provided with hooking resources (24) which are pivoting. Thesehooking resources (24) are pivoting and mounted on the insert (2) so asto be handled from the same lateral implantation face as the otherelements, by placing the hook-shaped portion against the opposite edgeof the spinous process. In some embodiments of the pivoting hookingresources (4, 24), they are preferably lockable in their rotation, sothat once they are placed on the opposite edge, the risk that theyrotate in the opposite direction is limited. Thus, it is preferablyprovided that locking resources (241) allow locking the pivoting of thehooking resources (4, 24) (or at least resources limiting the risk thatthe pivoting hooks rotate in the opposite direction, that it to say thatthey disengage from the edge of the spinous process). For example, cuts,tangs, teeth or notches (241) opposing the pivoting of the hookingresources (24) in a direction away from the spinous process can beprovided to abut the hooking resources (24). Alternatively, at least onetooth on a flexible structure that clips onto the edge of the pivotinghooking resources (4, 24) can be provided. On the other hand, in someembodiments of these pivoting hooking resources (4, 24), actuatingresources (240) are provided for ease of pivoting. Thus, for example asshown in FIGS. 20A and 20B, the hooking resources (4, 24) are formed byrotating a hook (24) mounted on an axis (240) mounted freely rotatablein the insert (in this example, but possibly on the implant in otherexamples). In the same or similar manner as described above for theactuation means (280) of the pivoting hooks (28) for bone anchoring, theaxis (240) may include a structure for its actuation by a particulartool (for example, in the illustrative and nonlimiting example shown, ahexagonal head manipulated by various types of known tools).

In some embodiments, the hooking resources (4, 24) are formed by theinsert (2), for example by the sigmoid insert which is preferred in thiscase. Such type of insert (2) may include, at its rear end, ahook-shaped extension (24) to hook the opposite edge of the spinousprocess along which this insert runs, for example as shown in FIGS. 21A,21B, 21C and 21D. In these embodiments, the shape of this hook extension(24) will be adapted to the shape and size of spinous process and to theradii of the plate (for example the shape of the sigmoid) to allow forhooking the opposite edge of the spinous process during the introductionof the insert (2) in the implant (1). In some embodiments, the insert(2) includes a plurality of withdrawal stops (20), but no insertion stop(25). Thus, in some embodiments, the retaining mechanism will be formedonly by withdrawal stops (20) and the extension (24) which abuts on theopposite edge of the spinous process and thus forms an insertion stopfor the insert (2). Preferably, a plurality of withdrawal stop will bechosen, for example in the form of flexible tabs (20) as detailed inthis application. The plurality allows the insertion of the insert (2)to be gradual and variable in the implant. Thus, depending on the height(or length, i.e., dimension along the X axis) of the spinous process,the insert will abut on one tab (20) more or less close to the anterioror posterior end of the insert, when its hook extension (24) abuts onthe opposite edge of the spinous process. Preferably, this type ofmechanism will be configured with the curvature of the insert and thecurvature of the hook extension providing a good hold on the oppositeedge, whatever the tab (20) which stops the insert (2). The plurality oftabs (20) forms a mechanism similar to a rack for adjusting the hookingof the spinous process by the insert. The desired maximum separation canthus be chosen, for example with a continuous contact between the hookextension (24) and the opposite edge of the spinous process or with aslight play between the hook extension (24) and the opposite edge of thespinous process. For such a rack mechanism with several tabs, thehousing accommodating the tabs will preferably be large enough to allowthe unfolding of the tabs that have already passed the stop surface(122), so as to minimize or avoid unintentional folding of the tab (20)which corresponds to the stop position suited for the desired maximumspacing of the spinous processes. As seen in FIG. 21C, the flexible tabs(20) are preferably close to each other, to allow for fine tuning, butalso possibly so that they strengthen each other. However, with thisarrangement, when a tab closer to the front end than the other tabsfolds by encountering a wall of the passageway in the insert, it willpress on the following tabs and tend to fold them. So here, the housingin which lies the stop surface (122) within the implant (1) is largeenough to avoid the problem of unwanted folding. For this, the housingmay have dimensions along the axis of the passage through the implant,at least equal to the dimension between the free ends of the last tab(the posterior) and the first tab (most anterior). In these embodimentsof insert (2) provided with a hook extension (24), the implant can havea hook-shaped wing to hook the opposite edge of the spinous processother than the one hooked by the insert, or provide anchoring resourcesfor this other spinous process (or even simply provide no retainer forthe other spinous process if one wants only to improve the retaining ofthe implant without limiting the distance between the spines). In theexamples of FIGS. 21A and 21B, the implants (1) shown have a wing (12)extended by an extension (24) forming hooking resources for a spinousprocess. It should be noted here that the curvature and extent of thishook-shaped extension (24) of the wing is designed so that the implantcan hook the opposite edge of the other spinous process (not the onehooked by the insert), according to the chosen location for the implant,in a manner similar to that shown in FIGS. 17A, 17B and 17C. Thus, thisextension should not extend too far or be too curved to prevent it frompassing the opposite edge of the other spinous process, but still haveenough curvature to provide the hooking function.

In some embodiments, the hooking resources (4, 24), forming a retainerfor retaining the implant and/or the spinous processes, are formed by atleast one hooking device (4) distinct from the implant (1) and insert(2). This allows adding the hooking device (4) if desired and allowsthis device to be used with any type of implant described in the presentapplication, preferably with an attachment structure or other means ofconnecting or attaching this hooking device on the implant (for exampleas detailed hereafter). This distinct type of device (4) has theadvantage, in particular compared to the above embodiments where it isthe insert that combines the two functions, of avoiding the insert (andits mechanism for retaining it within the body) from bearing theextension forces exerted by the patient bending frontward. Variousillustrative and nonlimiting examples of such hooking devices (4) areshown in FIGS. 22A, 22B, 22C and 22D and FIGS. 23A, 23B, 23C and 23D. Itwill be understood from the present application that such devices aredistinct structures from implants and inserts used for interspinousimplants of various types, including those presented in thisapplication. Thus, these distinct hooking devices may be claimed as suchin association or not with an interspinous implant, of the type of thisapplication or not. Indeed, in some embodiments, the hooking device (4)comprise linking or connecting resources (246) for linking or connectingthe hooking device (4) to the implant (1) and/or the insert (2). Theimplant (1) and/or insert (2) can then comprise complementary resources(e.g., slot 245 as shown in FIG. 23A) for receiving the linkingresources (246). Thus, these hooking devices (4) may be associated withand linked or connected to implants, for example the type of thisapplication using an insert (2). In the case of implants different fromthose presented in this application, but linked to such a hooking device(4), it is possible to provide an extremely simple interspinous implant,for example simply forming a block to maintain a minimum distancebetween the spinous processes, while hooking device (4) form a structurefor holding the implant in the interspinous space (by its link to theimplant) and a structure for maintaining the maximum spacing between thespinous processes. Such embodiments provide a simple alternative withthe advantage of a unilateral and minimally invasive implantation. Inother embodiments, the hooking device (4) does not include linkingresources for the implant or the insert and can therefore be used alone,although they may still be associated with an interspinous implant,which may generally not have the complementary linking resources (245)and will then preferably be provided with resources for keeping itstable in the interspinous space (as wings and/or insert in the presentapplication for example).

In some embodiments, these hooking devices (4) preferably comprise twoparts, preferably in the form of plates, each comprising, on the onehand, a curved portion forming a hook (24) for hooking the oppositeedges of adjacent spinous processes and, on the other hand, at least oneattachment structure (243, 244, 42, L, 41, 46, 47, 48, 49, L2, L3, L4,44, 45). For example, one or both parts may comprise a female structure(244) receiving a male structure (243) of the other part, so that bothparts can be attached to each other. Preferably, attachment structuresare provided for adjustable attachment to enable adjustable fastening ofboth parts of the hooking device and obtain a hooking device (4) havinga height (dimension along the X axis) which may vary depending on thesize of the spinous process and the interspinous space. The result is ahooking device in which the distance between the two parts is adjustableand which allows controlling the spacing (the maximum distance) betweenthe spinous processes. FIGS. 22A, 22B and 22C show illustrative andnonlimiting examples of such adjustable attachment structures. Theseexamples include, first, a male portion (243) of one of the two parts ofthe hooking device (4), which include a series of teeth, cuts, notches,grooves or housings and, secondly, a female portion (244) equipped witha flexible tab, leg, tang, prong, or other protrusion configured toengage the teeth, cuts, notches, grooves or housings of the male part.Preferably, flexible tabs are chosen with one or more teeth to engagenotches, so as to facilitate the setting of the penetration of the maleportion into the female portion. The notches are then oriented to opposethe withdrawal of the male portion, so that it can be pushed easily intothe female portion to adjust the hooking device (4) to the size of thespinous processes and so that the hooking device (4) is fixed once thedesired size is achieved. It will be understood that the flexible tab orother protrusion can be provided on the male portion and that the seriesof teeth, cuts, notches, grooves or housing can be provided in thefemale portion, or even other arrangements for adjusting the height (orlength, that is along axis X) of the hooking device (4). With such anadjustable mechanism, it is possible to adjust the size of the hookingdevice (4) to the desired maximum spacing between the two spinousprocesses, with or without play, by compressing the spinous processes ornot (ie, by forcing the two spinous processes to approach each other ornot). It will be understood that various types of adjustable attachmentstructure are contemplated, such as a male portion sliding in a femaleportion and immobilized by a screw or pin passing through a portion ofthe female portion and pressing on or extending through the maleportion. For example, FIGS. 34A and 34B show an illustrative example ofthis type of adjustable attachment structure (243, 244, 42 L, 41, 46,47, 48, 49, L2, L3, L4, 44, 45). The male portion (243) enters thefemale portion (244) to a variable depth and its position is locked by aclamp (42), such as a screw for example. FIGS. 35A and 35B shows anotherillustrative example of adjustable attachment structure. Hooks (24) eachinclude a duct (44) in which enters a bar or rod (43) extending betweenthe two hooks (or brackets) (24) each comprising a clamp (45) to fixtheir position along the rod (43). However, the notches are generallypreferred because they facilitate assembly by avoiding the use of toollike required by a screw or nut and because they allow an easieradjustment thanks to the rack mechanism.

In some embodiments of the hooking device (4), each of its two partscomprises a curved portion (247) forming an offset so that the male andfemale portions are not aligned with the rest of the hooking device (4).Thus, these portions preferably remain parallel to the rest of thehooking device (4), but offset so that at least one instrument anchorage(151) of the implant remains accessible even when the hooking device (4)is placed on the implant (1), such as shown in FIGS. 22A and 23A forexample. In other embodiments, the male and female portions are alignedwith the rest of the hooking device (4), such as shown in FIG. 22C forexample. Indeed, depending on the depth of the implant (ie, dimensionalong the Y axis) and the presence or not of this anchorage (151) on theimplant, as well as the location of this anchorage (151) on the implant(1), it may not be necessary or desirable to provide such an offset(247). This offset (247), when provided, allows the hooking device (4)to be positioned in the middle of the height of the spinous process(dimension along the Y axis) and provides a hold as stable as possible.Nevertheless, it can be provided that the hooking device (4) is arrangedto be placed deeper between the spinous processes (closer to the frontof the patient). Inversely, the hooking device can be placed more at therear of the patient and be tightened so as to bring the spinousprocesses closer from each other by using the body of the implant as apivot so as to provide a (preferably slight) lordosis (the adjacentedges of the dorsal spines then being slightly less apart form eachother than the height of the body). On the other hand, the size of thehooking device (4) in the depth dimension (Y axis) can be chosen so thatit covers more or less of the depth of the edges of each spinousprocess.

Some embodiments of the hooking resources comprise an attachmentstructure for linking it to the implant (1) and/or the insert (2), asmentioned above. Thus, some embodiments of the hooking device (4)comprise connectors or other connecting means (246) for the implant (1)and/or insert (2), forming an attachment structure. These linkingresources (246) generally cooperate with complementary resources (245)of the implant (1) and/or the insert. For example, the hooking device(4) may have a male part (246) arranged to engage a female part (245) ofthe implant, or vice versa. In the illustrative and non-limiting exampleof FIGS. 23A, 23B, 23C and 23D, the male part of the hooking device (4)is formed by a protuberance (246), for example such as a dovetail (or aT shape or similar restraining shape), protruding for example from itsface intended to come into contact with the implant (1) and which isconfigured to engage the female part (245) of the implant on thecorresponding face of the latter. This protuberance (246) preferably hasa width smaller at its base than at its top end and cooperates with ahousing, channel, or slot (245) of complementary shape in the implant(1). The width is then larger at the bottom of the housing (245) than atits surface, complementarily to the protuberance (246) of the hookingdevice (4). In some embodiments, non-sliding linking resources can beprovided, such as a lug provided with a notch as in the case of thelatch (35) provided for attachment of certain bone anchorage resourcesdescribed in this application, cooperating with a recess in the implantand/or the insert.

However, in some embodiments, it is preferably that the linking resource(246) allowing sliding, along the X axis, relative to the implant (1).This type of sliding link is particularly advantageous because it allowsthe position of the two parts of the hooking device (4) to be adjustedin relation to each other and to the implant. Indeed, the inter-spinousspaces and the spinous processes themselves do not have the same sizedepending on the level along the rachis and of the patient receiving theimplant, so generally it is advantageous to obtain adjustablepositioning of each hook (24) of the hooking device (4) in relation tothe spinous processes. This avoids having to dimension and/or configurethe hooking device (4) or a portion of it depending on the size of thespinous processes. Thus, to facilitate the coupling between the implant(1) and the hooking device (4) and get an adjustable device, it thehousing (245) of the implant may, for example, form a groove opening onat least one side of the implant, such as the upper and lower surfacesin the example shown in FIG. 23A, and that the protrusion (246) form arail to slide into the groove of the implant, as shown in FIGS. 23A and23B. This type of link is sufficient because the desired fixation of thehooking device (4) on the implant principally concerns the Z axis (andmay concern the Y axis too) and the fact that the implant (1) can sliderelative to the hooking device (4) along the X axis is not a problemsince these latter will be held together by their relations with theedges of the spinous processes. Instead, this sliding along the X axisallows the two parts of the hooking device (4) to be as adjusted to thesize of the spinous processes, and allows such adjustment to beperformed during the implantation itself. The result is a stableassembly, in particular by adjusting the penetration of the male portioninto the female portion of the hooking device (4), to adjust the maximumseparation of the spinous processes. It is therefore understood that inembodiments where the hooking device (4) is arranged to be slidablerelative to the implant and of adjustable height in relation to thespinous processes, the implant (1) can be inserted first in theinterspinous space, then the insert (2) can be introduced in theimplant, then the rail (246) for attachment of the hooking device (4)can be introduced into the groove (245) of the implant, and then thesliding of the two parts of the hooking device (4) can be adjustedrelative to the implant. All these operations can advantageously beperformed from one side face of the spine, which facilitates theimplantation as described in this application.

Various embodiments may include hooking resources (4, 24) having atleast one attachment structure on the implant and/or on the insertand/or at least one attachment structure between two parts of thehooking resources (mainly the hooks or brackets). The examples of bar orrod and of male and female portions provided above are not exhaustiveand various types of attachment structure (243, 244, 42 L, 41, 46, 47,48, 49, L2, L3, L4, 44, 45) can be provided. For example, FIGS. 30, 31,32 and 33 show other embodiments of hooking resources (4, 24), in whichthe attachment structures include at least one flexible link (L) orligament (L) which may for example be of the type described below as aretainer for the implant. In some of these embodiments, the hookingresources preferably comprise two hooks (24) each hooking one spinousprocess and connected together by at least one ligament (L). Preferably,the insertion of the ligament (L) on the hooks (24) is obtained byadjustable resources so as to adjust the distance between the two hooks(brackets). Thanks to the flexibility of the ligament, these embodimentsare particularly advantageous because they facilitate the adjustment. Inaddition, the ligament may have elasticity allowing application oftension during the adjustment. Thus, the maximum spacing between thespinous processes may be limited to a range depending on the tensionapplied to the ligament during its installation. Various options areprovided for the adjustment of the ligament and examples of thesepossibilities are shown in FIGS. 30, 31, 32 and 33. In these examples, afirst end of the ligament (L) is attached to a first hook (24). Forexample, a loop (L3) at one end of the ligament (L) is attached to thefirst hook (24).

In some illustrative and non-limiting examples of hooking resources (4,24), shown in FIGS. 32 and 33, this loop (L3) passes in the first hook(24), and a loop (L3) of a second ligament (L) passes in the second hook(24). Once the two hooks (24) are in place, the two ligaments (L) aremanipulated to extend towards each other and they are both threaded intoa locking means (41), such as a pressure-crimped attachment, collar,clamp, crush sleeve, etc. This type of locking means (41) may naturallyhave various shapes, including cylindrical (FIG. 33) or rectangular(FIG. 32). In addition, this type of locking means (41) may havenotches, teeth, or hooks on the inside to improve the retention of theligament and may have slots to facilitate the crushing of the ligamentduring crimping (for example in FIGS. 32A and 32B in which these twocharacteristics of slots and notches are combined). FIGS. 32A and 33Ashow this type of arrangement before the crimping of the locking means(41) while FIGS. 32B and 33B show the same arrangement once the crimpingis performed.

In another illustrative and non limiting example of hooking resources(4, 24), shown particularly in FIG. 30A, the ligament (L) is attached toa hook (24) through the loop (L3) at one end and extends toward theother hook in which it can pass through at least one passage (46). It isgenerally preferred to have a plurality of passages (46) for adjustingthe length of the ligament (L) (and thus its tension if it is elastic)by choosing one or other of the passages (46) in the second hook (24).The second end of the ligament (L) has a hook (L4), for example attachedto the ligament with a weaving, a loop or a crimping mechanism. Theligament extends from the second hook to the first hook at which thehook (L4) of the ligament (L) can be inserted into a plurality ofhousings (47) allowing adjustment. FIG. 30A, with its expansion in FIG.30B, shows this arrangement before insertion of the hook (L4) of theligament in the housing (47) of the first hook, while FIG. 30C, with itsexpansion in FIG. 30D, shows the arrangement with the hook (L4) of theligament (L) introduced into the housing (47) chosen. The shape of thehook (L4) of the ligament provides an adequate lock which, with thetension of the ligament (L), prevents the ligament from withdrawing.FIG. 30E shows a top view of the ensemble.

In another illustrative and non limiting example of hooking resources(4, 24), shown particularly in FIG. 31A and its expansion in FIG. 31B,the first hook (24) has an axis (48) of rotation. A rod, perpendicularto this axis (48) and carrying a plurality of fingers (49) substantiallyperpendicular to the rod, is mounted free in rotation around this axis(48) to allow pivoting of the fingers around the axis of rotation (48).Loop (L3) of the first end of the ligament (L) is fixed around the axis(48) of rotation, as shown particularly in FIG. 31C (this loop was notshown in FIGS. 31A and 31B to better show the axis and pivotingfingers). The ligament extends from the loop (L3) to the second hook inwhich it can pass through at least one passage (46). It is generallypreferred to have a plurality of passages (46) for adjusting the lengthof the ligament (L) (and thus the tension if it is elastic) by choosingone or other of the passages (46) in the second hook (24). The secondend of the ligament (L) has a second loop (L2) which can be slipped overany of the fingers (49) of the first hook (24) to allow adjustment ofthe insertion of the ligament (L) on the first hook (24). The rod (andthe plurality of fingers (49) that it bears) is designed to be foldedtowards the first hook. Locking means are provided for retaining theplurality of fingers (49) in folded position. Preferably, the fingersare maintained in the thickness of the hook (24) so that it does not jutout when in folded position. For example, as shown in FIGS. 31C and 31D,the rod and the plurality of fingers (49) are arranged to fit in awindow on the first hook (24) and to be retained in this window, forexample using a clipping mechanism. The fact that the ligament (L) canbe slipped over a finger facilitates the adjustment and the fact thatthe fingers rotate around the axis facilitates the tensioning of theligament when locking it. Note that the adjustment or setting can alsobe carried out during the passage of the ligament in the passages (46)of the second hook. Note also that in the various examples above, theloops (L3, L4) of the ligament may have been provided in advance or canbe performed by the surgeon himself during the implementation, forexample by folding a free end of the ligament (L) on itself and sewingthe end to a selected position on the ligament (L).

It will therefore be understood that in some embodiments, a firstretainer means formed by the insert is complemented by a second retainerformed by a first hooking resource having a hook partially surrounding afirst spinous process. Both retainers can be complemented by a thirdretainer formed by a hooking resource having a hook partiallysurrounding the second spinous process. This second hooking resource canthen provide, in cooperation with the first hooking resource (when thehooking resources are connected to the implant and/or to each other), afunction of retaining the spinous processes at a determined spacing orrange of spacings, in addition to the function of retaining the implant.

In various embodiments, particularly the preferred ones, that is thosein which a first wing lies along a lateral face of a spinous processwhile the second wing lies along the other face of the other spinousprocess, various types of retainers for retaining the implant and/or thespinous processes are provided, replacing or supplementing the insert(2), the anchorage or the hooking means or resources described above.

Advantageously, in certain embodiments, the retainers of the implant arepreferably arranged in a substantially symmetrical fashion to thearrangement of the body (10) with respect to the sagittal plane (A)passing through the center of the implant (1), but the different partsof these retainers are not necessarily symmetrical to one another.

In certain embodiments, the at least one retainer has/have a flexibleconnector (L) such as a cord or lace for example, which passes throughthe body (10). The flexible connector, also called a “ligament” in thepresent application with reference to its physical properties and itsuse as a connector between elements in relation to the skeleton) can becomposed of synthetic fibers, such as Dacron® polyester fiber producedby E.I. du Pont de Nemours and Company of Wilmington, Del. for example,and/or other polymers or plastics, and/or other suitable materials. Tosuit the use to which it is put, the connector or ligament mustpreferably have good resistance to elongation and generally show acertain elasticity allowing it to be stretched during its implantationand/or after implantation when it is subjected to forces due to themovements of the patient. Often, such a connector is in fact made offibers, generally woven (or knit or felted) to lend elasticity to theconnector. These fibers are generally strong and the connector istherefore robust despite its elasticity.

Such a flexible link (L) can be included in the attachment structure ofthe hooking structures (4, 24) as detailed above. On the other hand,such a flexible connector (L) can also be used itself as a hookingresource or as a means of hooking the spinous processes, similarly towhat is described for the latter in the present application, with thedifference that the flexible link lies generally along the two faces ofthe spinous processes instead of only hooking onto one edge of them froma single lateral face. This flexible connector (L) can either passthrough the spinous processes, being then called “trans-spinous,” orencircle the spinous processes, then being called “peri-spinous.” Itwill be noted, however, that a trans-spinous path can be selected forone of the two spinous processes and a peri-spinous path for the otherspinous process, for various reasons such as for example when an implantfor multilevel surgery is desired as explained in the presentapplication (the trans-spinous path being then preferred for the spinousprocess that will be located between the two implants).

In the embodiments where the flexible connector (L) is trans-spinous, itpasses through the dorsal spinous process at a hole previously made bythe surgeon through the spinous process, that is along an axis that isnot parallel to the sagittal plane (or of the spinous faces), preferablyan axis substantially perpendicular to the sagittal plane (A).

Preferably, a passage (100) passing through the body (10) and designedto receive the flexible connector (L) allows the latter to run from onelateral face (E4, E5) to the other (E5, E4) between the two spinousprocesses (EI, ES). In the case where the flexible connector is designedto be trans-spinous, the wings (11, 12) of the implant preferably alsoinclude a hole or duct (125, 128, 110) serving as a passage and/orattachment for the flexible connector (L). Especially advantageously,the passage (100) passes through the body (10) from one lateral face(E4, E5) to the other (E5, E4) following an oblique path, orienting theflexible connector (L) toward the portion of each lateral face (E4, E5)not having a wing (11, 12), as can be seen particularly in FIG. 25B.

In certain embodiments of the trans-spinous flexible connector, thisflexible connector (L) has a first end integral with a first wing (11),preferably by means of an attachment of the flexible connector to thatwing. For example, the flexible connector (L) is affixed to the wing(11) or attached at a hole or duct (110) in the first wing (11), forexample by a knot in the flexible connector which bears on the edges ofthe hold or duct passing through the wing (11) and in which the flexibleconnector (L) runs. The second end of the flexible connector (L) passesthrough the hole or duct (125) in the opposite wing (12). In FIG. 25B,the holes or ducts (110, 125) in the wings (11, 12) are shown as beingarranged symmetrically from one wing to another, but any otherarrangement can be contemplated, in particular if it is desired that theflexible connector (L) run higher or lower relative to the two dorsalspinous processes (EI, ES), that is more toward the edges of the dorsalspinous processes opposite the edges between which the implant isinserted. In addition, these holes are shown centered relative to thedepth of the implant (Y axis), but other arrangements can also beconsidered if it is desired that the flexible connector run more towardthe crests or more toward the vertebral bodies, in other words morerearward or more forward of the patient, respectively. It is understoodthat in various embodiments, the flexible connector (L) lies along atleast part of the lateral faces of the two spinous processes and hassubstantially an S shape in the coronal plane (defined by the X and Zdirections).

Locking means or resources (125, 128, 1280) is preferably provided forlocking the flexible connector (L) relative to the implant, generallyrelative to this second wing (12) since that is the one that remains onthe side through which the interspinous space is approached in thefigures shown (the reverse configuration can also be contemplated, asthe body is often symmetrical). For example, this locking means cancomprise a conical or trunconical element having a duct at its centerallowing passage of the flexible element (L), and preferably a slitalong part or all of its height to facilitate its compression. Thisconical element can then be set on the ligament, then inserted into theduct (125) to be compressed there and thus clamp the flexible connector(L). An example of such locking means consisting of a truncated cone(1280) is shown in FIGS. 26A and 26B. This split truncated cone (1280)is designed to receive the ligament (L) and to be inserted into a duct(128) provided in a boss on the body. In the example of Plate 25 in thefigures, such a truncated cone would be inserted into the duct (125) inthe second wing (12). In the example of FIGS. 26A and 26C, such a duct(128) is oriented parallel to the wing such that the path of theligament is peri-spinous for this spinous process. In FIG. 26B, it isseen that the hole or duct (110) in the first wing is located near theupper edge of the lower spinous process. It is understood that with theoblong or elliptical coronal section of the spinous processes, thislocation leaves enough space for a knot to be set between the spinousprocess and the first wing (11) of the implant. Thus, in this example, aknot (not shown) in the ligament constitutes an attachment of theligament (L) to the implant. This ligament, with its knot at one end tobear on the first wing (11), passes through the duct (110) in this firstwing (11) then goes around the lower spinous process to pass through thepassage (100) in the middle of the body, then goes around the upperspinous process to be locked by this locking means (128, 1280). It isunderstood by examining the figures in Plates 25 and 26 that the implantcan be designed with ducts (110, 125) perpendicular or parallel (128) tothe longitudinal axis of the implant (X axis) and set at differentdistances from the ends of the wings, so that an implant (1) having onlytwo wings and having only one ligament (L) as a retainer can be peri- ortrans-spinous. It is also understood how a peri-spinous path is obtainedfor one spinous process and a trans-spinous path for the other spinousprocess, by using various combinations of the configurations describedabove. It will also be noted that they are not necessarily mutuallyexclusive. Indeed, FIG. 26 shows for example that the duct perpendicularto the second wing (12) can be retained in addition to the duct (128)parallel to the wing (this duct, not labeled in this figure, is retainedan visible behind the ligament at the second wing).

An example of placement of the interspinous implant the retainer whereofis a flexible connector (L) is illustrated in FIG. 25C. This placementoccurs for example in the following manner: The flexible connector (L),attached to a first wing of the implant (the lower wing (11) in FIG.25C), is run into the interspinous space which is to receive theimplant, then by the use of a curved tool (such as a curved needle forexample), through a first spinous process (or around the spinous processin the case of a peri-spinous implantation). The connector is theninserted through the passage (100) in the implant, then again into theinterspinous space to be run into (or around) the other spinous processusing a curved tool, for finally run into the hole or duct (125) in thesecond wing (12). Finally, the surgeon pulls on the free end of theflexible connector (L) sliding in the implant and the spinous processes,while inserting the first wing first to place it on the lateral spinousprocess face opposite that where the approach is performed. By pullingon the flexible connector, the surgeon allows the two wings of theimplant to each press against one lateral face of one of the two spinousprocesses. The surgeon then locks the flexible connector (L) relative tothe second wing and can cut off the protruding part of the flexibleconnector.

In certain embodiments, of which illustrative and non-limiting examplesare shown in FIGS. 27A, 27B, 27C, 27D, 27E and 27F, the retainer of theimplant relative to the spinous processes, and particularly formaintaining the position of the body (10) relative to the two dorsalspinous processes (EI, ES), comprises a so-called complementary body(90), with dimensions designed to maintain a distance between theadjacent edges (E2, E3) of the two spinous processes (EI, ES) anddesigned to be placed on top of the body (10) such that two wings (91,92) of the complementary body (90), each extending along an oppositelateral face (generally substantially parallel to said sagittal plane),are each located on a lateral face opposite to that of a wing (11, 12)of the body (10). It is therefore understood that, in these embodiments,the two bodies (10, 90) in fact constitute mutually complementaryhalf-implants. Thus, these two half-implants constitute for example,once assembled, an interspinous implant with an H or X shape in top view(in the coronal plane defined by the X and Z directions), the two wings(11, 12) of the body constituting two opposite half-branches of the H orX and the two wings (91, 92) constituting the other two oppositehalf-branches.

In certain of these embodiments, the wings (11, 12, 91, 92) of each ofthe two bodies (10, 90) extend over the part of the other body (90, 10)which is not provided with a wing. The wings extend for example, ontheir lateral face parallel to the sagittal plane (A), up to the lateralface of the other body (90, 10). In other words, the dimensions of thewings (11, 12, 91, 92) in depth, that is along the Y axis, are greaterthan those of the body, such that the wings of each of the two bodies(10, 90) extend over the part of the other body (90, 10) which is notprovided with a wing in addition to the part of the body from which theyoriginate. Thus wings can be provided for both bodies which havedimensions of depth (i.e. along the Y axis) substantially equal to thoseof the two stacked bodies (in their parts located between the wings).Thus the wings of each body complement the wings of the other body toconstitute a complete implant the wings whereof extend to the same depth(along the Y axis) as the two bodies combined. The wings can also bedesigned to cover substantially the same surface (substantially parallelto the sagittal plane) as the two stacked bodies, but it will be notedthat they can nevertheless cover a larger or smaller surface accordingto various possible variations. Moreover, the height dimensions of thewings (along the X axis) can vary so as to lie along a greater orsmaller portion of the lateral faces (E4, E5) of the spinous processes(EI, ES).

Locking means (910, 900, 101) are designed to maintain the two bodies(10, 90) stacked by fixing their positions relative to one another, suchthat the wings (11, 12, 91, 92) of each body (10, 90) maintain theorientation of the other body (90, 10) relative to the two dorsalspinous processes (EI, ES). Thus, it will be understood that thecomplementary body (90) constitutes a retainer for the implant byproviding the wings complementary to those of the first body. Inaddition, according to various embodiments, the two bodies (10, 90) canbe mounted so as to pivot relative to one another or to be separated anddesigned to be assembled together. The locking means then allow lockingof the position of the two bodies which constitute the ultimate implant.It will be noted here that the first body and the second body arementioned and that this could refer, respectively, to the body (10) ofthe implant and to the complementary body (90), but that theconfiguration could be inverted, so long as the locking means weresuitably arranged. The fact that the implant is made up of two bodieshas the advantage of facilitating implantation. For example, when afirst body is set between the spinous processes, with the wings lyingalong a first lateral face of each spinous process, the other bodymounted pivotably on the first can have a different orientation fromthat of the first body, then be turned to a position, called thedeployed position, in which its wings lie along the other lateral faceof each spinous process. One example of this pivoting from a givenorientation to the deployed position is shown in FIGS. 27C and 27D. Inthe case of two separate bodies, they can be designed to be inserted inthe interspinous space either simultaneously or in succession. When theyare designed to be inserted simultaneously, as shown for example inFIGS. 27A and 27B, the two previously assembled bodies are insertedtogether, but the wings of the first body will be placed so as to liealong a first lateral face of each spinous process, while the secondbody will have a different orientation from that of the first body(perpendicular to it, for example) to facilitate insertion of the firstbody, then once that is completed it will be turned to the deployedposition. In the case of two separate bodies designed to be insertedinto the interspinous space in succession, as shown for example in FIGS.27E and 27F, the first body is inserted and its wings are placed to asto lie along a first lateral face of each spinous process. The secondbody will then be inserted afterward, with an orientation different fromthat of the first body already in place (oblique or perpendicular forexample), then it will be turned to the deployed position.

It will be noted that in certain embodiments, and particularly in thecase where the two bodies (10, 90) are designed to be inserted insuccession, one of the wings of the second body can be dimensioned tofacilitate its insertion into the interspinous space where the firstbody is already situated. Thus, as shown for example in FIG. 27F, asingle wing (91) of the complementary body (90) extends over the entirelateral face of the body (10) which is not provided with wings, whilethe other wing (92) of the complementary body (90) does not extendsubstantially farther than the body (90) and does not cover the otherlateral face of the body (10) which is not provided with wings. The factthat this second wing has dimensions of depth (along the Y axis) whichdoes not exceed or exceeds only slightly the dimension of the bodyallows facilitation of the insertion of the complementary body (90) intothe interspinous space when the body (10) is already in place betweenthe two dorsal spinous processes (EI, ES) because it will need lessspace for passing (which may prevent pushing or even wounding thesubspinous ligament). The second wing of this complementary body can,however, have larger dimensions without complicating the implantation.

It is therefore understood that in these various embodiments, the twobodies (10, 90) will pivot relative to one another, whether or not theyare mounted one on the other and are therefore inserted simultaneouslyor successively into the interspinous space; this pivoting willpreferably be centered on the center of the implant, for examplecentered on an axis oriented along the Y axis and passing through thecenter of the implant. Locking means (910, 900, 101), eccentric (offset)with respect to this pivoting axis, are therefore provided to clamp therelative position of these two bodies and the latter constitute the atleast one retainer of the implant (for one another). For example, inFIGS. 27C and 27D, the two bodies are mounted so as to pivot about anaxis of rotation (not shown). A first of these two bodies, for examplethe body (10), has for example a central stud and the second of the twobodies, for example the complementary body (90), has a matching recessso as to pivot about the stud while remaining stacked on top of thefirst body (10). Provision can be made for the two bodies to beassembled by a rotation pivot holding them together to avoid themdisassembling, while still allowing them to pivot relative to oneanother. Locking means (910, 900) such as a screw for example (910)passing through a duct (900) in the complementary body (90) into a borethreaded into the first body (10) to be screwed into it, thus allowingthe two bodies to be locked together. It will be noted that theeccentricity (offset) of these locking means (900, 910) not only allowsthe rotation of the two bodies to be locked, but also facilitates accessfor locking when the implant is in place between the spinous processes.The embodiments having two bodies pivoting relative to one another aregenerally arranged to allow rotation such that a portion of each of thewings (91, 92) of the complementary body (90) can come into contact witha portion of a wing (11, 12) of the first body (10), as shown forexample in FIG. 27C, to facilitate the insertion of the implant betweenthe spinous processes (EI, ES), then so that the rotation allowsdeployment of the wings (91, 92) of the complementary body (90) to adeployed position where the two bodies form the interspinous implantwhose wings are able to lie along the spinous processes, as shown forexample in FIG. 27D. It will be noted that the eccentric (offset)locking means can possibly be oriented along an oblique axis as in FIGS.27E and 27F for example. An oblique axis generally facilitates lockingwhen the implant is in place between the spinous processes. Indeed, oncethe implant is in place between the spinous processes its body is in theaxis of the spinous processes and access to these locking means can beimpeded by the interspinous and subspinous ligaments, injuries to whichwill preferably have been minimized. The eccentricity (offset) and/oroblique axis of the locking means (910) therefore facilitates access tothem to allow locking or unlocking of the two bodies.

In certain embodiments, particularly those where the two bodies areseparate but pre-assembled together and designed to pivot relative toone another, as shown for example in FIGS. 27A and 27B, locking means(or resources) can constitute the rotation pivot for the two bodies. Forexample, in these figures, a screw (910) running through a duct (900) inthe complementary body (90) to a threaded bore in the first body (10) tobe screwed in there is set in the center of the implant and can serve asa rotation pivot. In this example, but also in the embodiments where thetwo bodies are designed to be inserted in succession, as for examplethose shown in FIGS. 27E and 27F, rotation locking means are providedfor preventing the rotation of the bodies relative to one another. Forexample, projecting studs (101) on the first body (10) are arranged tocooperate with matching recesses (not shown) in the complementary body,when the latter has attained its deployed position, as shown in theseFIGS. 27A, 27B, 27E and 27F. Driving the screw (910) then allows thecomplementary body to come into contact with the first body (10) andallows these studs to penetrate into the recesses in the complementarybody to lock the rotation. It is therefore understood that with suchstuds, the two bodies assembled using the screw are stacked but are heldat a distance from one another, requiring a larger space for theirinsertion between the spinous processes than in the embodiments having acentral rotation pivot and eccentric locking means, like those shown inFIGS. 27C and 27D detailed above, for example. In the embodiments ofFIGS. 27E and 27F, the axis of the locking means is eccentric withrespect to the implant and obliquely oriented, facilitating the lockingof the two bodies inserted in succession between the spinous processesas detailed above.

The present application describes in detail various embodiments of animplant comprising firstly a body (1) including at least two wings (11,12) extending so as to each lie along a lateral face of a spinousprocess and additionally at least one retainer for the implant (andpossibly for retaining the spinous processes). Various possiblearrangements for these various types of retainers (2, 3, 4, 7, 111, 121,221, 24, 28, 29, L, 90), as well as their respective advantages, aredescribed in the present application. Moreover, these various types ofimplant retainers are not necessarily mutually exclusive, whether theyalso constitute retainers for the spinous processes or not. Thus forexample the flexible connector (L) constitutes a particularlyadvantageous retainer due to its ease of implantation given that it is aflexible element, but in certain cases (certain pathologies forexample), a greater stiffness in the support is preferred and it ispossible, instead of replacing the ligament (L) with another design, tocombine it with another design, such as for example an insert (2).Examples of such a combination of a flexible connector (L) and an insert(2) are shown in Plates 28 and 29 of the figures. In such a combination,the insert constitutes the retainer for the rigid implant while theligament constitutes a more flexible retainer and will thereforeessentially play the part of restraining the motion of the spinousprocess which the insert (2) allows (hence mainly extensional motion,but also possible rotational motion if the wings and the insert aredesigned to allow lateral clearance). The ligament or flexible connector(L) can be combined with bone anchorage means (3, 7, 111, 121, 221, 28,29), as for example a staple (3), or with spinous process hooking means(4, 24), but in these cases, the flexible connector (L) will generallyplay essentially its part of retaining the implant while the role ofretainer for the spinous processes will essentially by provided by theother means. Nevertheless, the combination of the two designs offersgreater safety for the implant, particularly through synergisticeffects. For example, when a ligament (L) surrounds two spinousprocesses and a staple (3) or a hooking means (4), the latter are heldon the spinous processes and will be less liable to become unhooked.Likewise, when a ligament supplements a hooking means consisting of aninsert (2), the ligament (L), by preventing the spinous processes fromspreading, relieves the withdrawal stops of the insert (2).

In certain embodiments, examples of which are shown in Plates 28 and 29,the implant comprises an insert constituting a retainer for the implant(1) and a ligament also constituting an implant retainer, but primarilya retainer for the spinous processes. In the example of FIGS. 28A and28B, the ligament (L) or flexible connector is used peri-spinously for afirst spinous process (for example the upper spinous process) andtrans-spinously for the second spinous process (for example the lowerspinous process). The ligament, for example with a knot bearing on theentrance of the duct (128) oriented parallel to the first wing (12) runsalong this first wing (12) then runs around the first spinous process(the upper spinous process (ES) in FIGS. 28A and 28B), then runs alongthe rear end of the insert (2). The insert (2) then preferably includesan indentation, a cutout or a notch separating its rear end into twobranches (22, 23), as can particularly be seen in FIG. 28D, tofacilitate passage of the ligament (L). The ligament (L) then runsthrough a passage (100) through the body (10). This passage (100) ispreferably, in these embodiments, parallel to the passage (15) in theinsert, and for example provided in a wall of this passage (15) in theinsert, as can be seen particularly in FIG. 28C. The ligament thenemerges on the other lateral face of the implant and runs along thefront end of the insert. Preferably, this insert (2) includes anindentation, a cutout or a notch separating its front end into twobranches (220, 230), as can particularly be seen in FIG. 28D, tofacilitate passage of the ligament (L). This ligament then runs throughthe second spinous process (the lower spinous process (EI) in FIGS. 28Aand 28B), as can particularly be seen in FIGS. 28A and 28B, then entersa duct (156) passing through the second wing (11). Preferably, theentrance to this duct, or even the entire inner face of the wing, isprovided with a gutter or groove (157) to receive the ligament (L) so asto avoid the latter being squeezed between the wing and the spinousprocess, as can particularly be seen in FIG. 28C. A locking means (18)is provided for locking the ligament in its passage through the duct(156). Such a locking means can be constituted by a screw or otherelement that can be screwed into the body or by a rod (181) providedwith a hole (182) for passage of the ligament (L) and with a thread forscrewing on a nut (18), as can for example be seen in FIG. 28C. This rod(181), when the nut (18) is screwed on, rises within the body andsqueezes the ligament (L) between the walls of the duct (156) in theimplant and the hole (182) in the rod. The ligament thus squeezed islocked relative to the implant. The dimensions of the male and/or femalethread are preferably designed to prevent the ligament from beingcompletely crushed, or even cut through by the locking means, whilestill providing sufficient locking. In can be seen particularly in FIGS.28A and 28B that the ligament re-emerges from the implant on a lateralface, at the exit of the duct (156) in the implant and this free end canbe cut if it is too long, so as to avoid having it snag neighboringtissues for example. It is understood that for such an implantation, theligament is preferably first run into the duct (128) in the first wing,then hooked around the upper spinous process, then inserted in thepassage (100) in the implant, then run through a hole previously made inthe lower spinous process, and finally run into the duct (156) in theimplant, leaving enough slack in the ligament to facilitate themanipulation of the ligament (L) and the implant (1). Then, by insertingthe first wing (12), then the body (10) between the spinous processes,the surgeon can progressively pull on the ligament to apply the twowings of the implant against the spinous processes, then lock theligament.

In the example of FIGS. 29A and 29B, the ligament (L) or flexibleconnector is used peri-spinously for a first spinous process (but thelower spinous process this time, in this example) and trans-spinouslyfor the second spinous process (the upper spinous process this time). Inthis example, the ligament (L), with a knot bearing on the outside of ahole (125) through the first wing (12) runs through this wing (12) andthe upper spinous process, then runs along the rear end of the insert(2). The insert (2) preferably includes a indentation, a cutout or anotch separating its rear end into two branches (22, 23), as canparticularly be seen in FIG. 29B, to facilitate the passage of theligament (L). The ligament (L) then runs through a passage (100) throughthe body (10). This passage (100) is preferably, in these embodiments,parallel to the passage (15) in the insert, and for example made in awall of that passage (15) in the insert. The ligament then emerges onthe other lateral face of the implant and runs along the front end ofthe insert. Preferably, this insert (2) includes an indentation, acutout or a notch separating its front end into two branches (220, 230),as can particularly be seen in FIG. 29B, to facilitate the passage ofthe ligament (L). This ligament then runs around the second spinousprocess (the lower spinous process (EI) in FIG. 29A), then enters a duct(156) parallel to the second wing (11), being locked there by a lockingmeans (18), as described above for example with reference to Plate 28 inthe figures. Preferably the entrance to this duct, or even the entireouter face of the second wing (11) is provided with a gutter or a groove(157) designed to receive the ligament (L) so as to avoid having thelatter projecting too far outside the implant and snagging neighboringtissues for example. Likewise, it can be seen in FIG. 29A that theligament re-emerges from the implant on a lateral face, at the exit ofthe duct (156) in the implant and this free end can be cut if it is toolong, so as to avoid having it snag neighboring tissues for example. Itis understood that for such an embodiment, the ligament is preferablyfirst run into the duct (12) in the first wing, then hooked through ahole made previously in the upper spinous process, then inserted intothe passage (100) in the implant, then hooked around the lower spinousprocess, and finally run into the duct (156) in the implant, leavingenough slack in the ligament to facilitate the manipulation of theligament (L) and of the implant (1). Then, by inserting the first wing(12) then the body (10) between the spinous processes, the surgeon canprogressively pull on the ligament to apply the two wings of the implantagainst the spinous processes, then lock the ligament.

It is understood from reading the present application, while examiningPlates 28 and 29, that an implant with an insert and a ligament can becontemplated which is peri-spinous for both spinous processes ortrans-spinous for both spinous processes, by combining the variousdesigns described above. The various types of possible combinations ofthe various embodiments described will also be understood. In addition,it is understood that by using a peri-spinous ligament (L) for the twospinous processes, this ligament (L), particularly when it passes withinthe gutters or grooves (157) along the insert (2) and/or the wings (11,12), makes it possible to hold the insert (2) and the wings (11, 12) ofthe implant pressed against the lateral surfaces of the spinousprocesses, which provides a resource for compressing the spinousprocesses (for example and in particular by applying pressure on thelateral faces) stabilizing the implant, in addition to the stabilizationprovided by the peri-spinous hooking accomplished by the ligament (L).Thus, certain embodiments provide compression of the spinous processesfor stabilizing the implant by allowing the wings (11, 12) and theretention arrangement to be pressed against the lateral surfaces of thespinous processes. Such a compression of the spinous processes can beaccomplished, for example, with an implant that includes compressionresources arranged so that the wings (11, 12) and the retainers (2, 3,4, 7, 111, 121, 221, 24, 28, 29, L, 90) are pressed against the lateralsurfaces of the spinous processes.

In certain embodiments, the compression of the spines is obtained by theretainer itself, without requiring additional means, resources, orarrangement. For example, FIGS. 42A through 42C and 43A through 43D showembodiments wherein the compression can be obtained directly by theretainers. FIGS. 43, 44, 45, 46, 47 and 48 also show additional examplesof embodiments in which compression of the spinous processes is achievedthanks to the retainers themselves. These figures show a double insertwith two parts articulated about a common hinge. This structure will bedesignated for the following description of these embodiments asincluding two inserts (2) pivoting relative to one another about acommon hinge (250), even though these two inserts are in fact two partsof one and the same structure inserted into the implant (the terms“insert” or “double insert” will thus be used interchangeably in thesingular or plural, which is also the case for the term “retainer”). Inthis example, each of these two inserts (2) includes a curved plate (orbody) separated into two branches (253, 254), over at least a posteriorportion of the curved plate, such that the two inserts can be nested oneinside the other as previously explained with reference to possiblevariations for the embodiments such as those of FIGS. 1A through 1C and2A through 2C. Thus, one branch (253) of each insert (2) passes betweenthe two branches (253, 254) of the other insert (2) and the two inserts(2) can be inserted at the same time into the passage (15) and followtheir opposite paths without interfering. Preferably, the two insertsare connected by a common hinge (250), at their posterior end, enablingthe deployment of the two inserts from a folded position where theinserts are in contact or close to each other to a deployed position inwhich the inserts are spaced from one another. The deployment of twoinserts takes place in these embodiments due to the hinge and thecontact of the inserts with at least one wall in the passage (i.e., atleast one wall located in the axis of the passage and opposite theentrance of the latter), and the degree of deployment (i.e., theorientation of the inserts in the deployed position) depends on theposition of the hinge in the passage. Such a hinge is preferably formedby an articulation axis (250) on which are assembled, free to rotate,the posterior ends of the branches (253, 254) of each of the two inserts(2), for example thanks to eyelets (260) formed at these posterior ends.The axis (250), for example formed by a pin, screw, rivet, or otherstructure, may include, at a first end, a cap (252) forming a stop forretaining one of the inserts (2) in translation along the axis (250),the other insert then also being retained by its nesting with the firstone. Preferably, the eyelet (260) of the branch (254) which comes to astop against this cap (252) includes an enlargement (264) forming ashoulder for receiving and stopping the cap (252). This enlargementmakes it possible to receive the cap (252), preferably in such a waythat the latter does not project from the insert (2) once the ensembleis assembled, for example as shown in FIGS. 42A and 42C. Further, theaxis is preferably provided at the second end with a thread accepting anut (251), but other clamping structures may be used. In theseembodiments proposing compression of the spines, the pin may be longerthan the height of the two inserts that are slipped onto it, such thatthis nut (251) can be held at a distance from the second insert. As isparticularly visible in FIGS. 43A and 43C, this ensemble is insertedinto the passage (15) of an implant (1) provided with two wings (11, 12)on the same lateral face of the body (10) and this passage splits intotwo in the direction of the upper and lower surfaces of the body toguide each of the two inserts (2) in the direction of one of the spines.This passage is preferably provided with a longitudinal opening (158) onthe upper edge of the body (10), that is to say the edge that will besituated in the direction rearward of the patient. This longitudinalopening has dimensions designed to receive the articulation pin (252) ofthe two inserts (2) and allow it to slide along the opening as theinserts penetrate into the passage (thanks to the space or gap betweenthe nut and the second insert which allows the pin to slide along theopening). The nut (251) may be arranged so that it can be tightenedagainst the edges of the opening (158) in order to be able to block theposition of the pin (in translation along the opening) and of the insert(2) in the body of the implant. It is understood that thanks to thisarrangement the pin and the two inserts can be positioned according tothe width of the spines and that thanks to the pivoting of the insertsabout the pin and to their curvature, a compression of the spinesbetween the inserts (2) and the wings (11, 12) of the implant can beobtained. The degree of compression depends on the position of the pinin the passage (15) and of the nut (251) along the opening (158).Indeed, the position of the nut determines the orientation of the twoinserts because of their deployment thanks to their contact with atleast one wall of the passage (15) in the implant and this orientation(or the degree of deployment) will determine the compression of thespinous processes. By adjusting this position, more or less completepivoting of the two inserts (2) which bear on the bottom of the passage(15) is obtained, and the compression of the spines can be maintained bylocking this position by tightening the nut (251) which presses thedouble insert against the inner wall of the body wherein the opening(158) is provided, using the cap (252) of the pin (250).

In certain of these embodiments, an implant equipped with two insertshaving a common hinge can be supplied pre-assembled with the inserts, inthe folded position, inside the implant. A pin (81), such for example asthat shown in FIGS. 43A and 43B, can for example be provided forblocking the two inserts within the implant. Such a pin includes a shank(814) which passes between the branches of the two inserts assembled ontheir common hinge, as is particularly visible in FIG. 43B. Contact ofthe branches (253, 254) of the two inserts (2) with the walls of thepassage (15), on the one hand, and the shank (814) of the pin (81), onthe other hand, prevents the inserts from further entering and/orleaving the passage (15) inopportunely. Additionally, a notch (159) canbe provided in the opening (158) of the passage to receive a rib or aboss present on the pin. Thus, blocking of translation of the ensembleis completely provided for. In addition, the pin can include a head(812) including a stop (830) conforming to the outer shape of the nut(251) such that it cannot loosen inopportunely. Also, the pin can beprovided with a stem (810) so that it can be more easily withdrawn whenthe implantation of the implant is in progress, when it is desired toproceed with the positioning of the inserts (2). Such a stem (810) canbe provided, for example, with a cap (811) at its end make it easier togrip. Further, as can be seen in FIG. 43C, the entrance to the passage(15) can be flared, for example by means of at least one chamfer (154),so as to facilitate the insertion of the inserts (2) into the passage(15). It will be understood from the foregoing that an implant is thusavailable which can be pre-assembled with its two inserts. It is thensufficient to insert the implant having generally a T shape between thespines until the wings (11, 12) of the latter are pressed against thesame lateral face of the two spines, then to withdraw the pin (81) so asto be able to press on the inserts (2) at their common hinge until thedesired compression of the spines is obtained, then to tighten the nut(251) to lock the ensemble into the interspinous space. Preferably thebody of the implant, the passage and the inserts (2) with their pin willbe dimensioned so that even during maximum compression of the spines,the nut remains on the same lateral face as that by which the elementsare inserted into the interspinous space. Thus, for example, the nut(251) remains accessible from the same implantation side, so as tominimize the invasiveness of the operation, in particular by preservingthe supraspinous and inter-spinous ligaments (which could possibly beslightly pressed upon by the nut driving instrument, but whichpreferably will not have to be cut or damaged).

Preferably, this type of implant provided with two inserts having acommon hinge will be made of durable material. Metal or PEEK willgenerally be preferred because the large upper and lower openings of thepassages (15) that are necessary for the pivoting of the inserts and theopening (158) for guiding the inserts' pin impose heavy constraints onan implant of reduced size (suited to interspinous spaces).

It will be noted that in FIGS. 43A through 43D, the implant is providedwith wings (11, 12) which are not exactly aligned in the plane of theimplant's height (XY plane designed to be substantially parallel to thesagittal plane of the vertebral column), but are slightly oblique, toconform to the shape of the spines. Indeed, the spines are often thickerat their base than at their peak. Implants can therefore be provided,the wings (11, 12) of which are oriented so as to better conform to thisshape of the spines. This alternative configuration applies of course toall the embodiments described in the present application, whether animplant with a dual, sigmoid or other kind of insert is considered.Thus, the considerations provided in the present application regardingan orientation of the wings (11, 12) of the implant (1) in the sagittalplane must not be interpreted in a limiting way, but rather as includingthe possibility of a slight oblique offset, this concept being developedwith reference to the implantation of the implant between the spines aspreviously mentioned. It will further be noted that it is also possibleto provide in certain embodiments of an implant with two inserts havinga common hinge that the curved plate forming the inserts not have thesame thickness from one insert to the other, so that the inserts arealso arranged to conform to the shape of the spines. However, it willsometimes be preferable to have two identical inserts for obviousreasons of manufacturing cost, given that they can be assembledsymmetrically and that it is not necessary to produce different types ofinserts to make an assembly such as that of FIGS. 42A and 42C forexample. Finally, it will also be noted that points (111, 121) arepreferably provided on the wings (11, 12) of the implant, designed topenetrate into the lateral faces of the spines upon compression. Thus,the implant also adjusts itself in relation to the spines thanks to thelength of these points and the stability of the implant is improvedwhile still providing adequate compression. This further justifies apreference for two identical inserts rather than inserts of variablethickness because the improvement in production cost does not occur tothe detriment of quality and stability of the implant. On the other handthe inserts (2) in these embodiments are preferably provided withnotches (29) rather than points, to be able to pivot and lie along thespinous process more easily during compression and thus positionthemselves in the best way possible on the lateral faces of the spines.These notches (29) can be omitted but they are preferred for theirstabilizing role.

Preferably, this type of implant receiving two inserts having a commonhinge is provided with holding arrangements (150), formed for example ofa threaded hole near at least one corner of the implant, on the side ofthe wings (11, 12) and oriented obliquely (between the sagittal planeand the coronal plane, preferably closer to the sagittal), to allowgripping along an oblique axis facilitating access to the interspinousspace, while allowing access for a tightening tool for driving the nut.It is generally preferred to use two holding arrangements (150) toprovide good holding and to have a lever arm available for acting on theimplant, as already explained in the present application. Preferably,these embodiments with pivoting inserts are provided with a firstholding arrangement (or attachment resource) formed by a threaded holeand a second attachment resource formed by a simple hole, to facilitateassembly of the implant on an implantation instrument (by requiring onlya single screw). The second attachment resource is preferably located onthe same side of the implant, on the same side edge and with the sameorientation as the primary attachment resource, but near the oppositecorner. This type of implant is preferably implanted using a specificinstrument (5) of the type exemplified in FIGS. 44A and 44B. Thisinstrument preferably includes a main tube (50), preferably providedwith a handle (51) for gripping it. In some embodiments, a thumb wheel(52) is provided for adjusting the tightening of at least one step (500)arranged in the tube and penetrating into the holding arrangement (150)of the implant (for example a threaded rod for a threaded hole). Asexplained above, two holding arrangements are preferred on the implant.In the case of implants with double pivoting insert, it is generallypreferred to provide for the implant, at the back (referring to thepatient, that is to say the face disposed toward the rear of thepatient), a threaded hole (150) and a simple hole (151). Thus, forexample, the main tube (50) contains a threaded rod (500) configured tobe screwed into the threaded hole (150) and the instrument has a branch(502) parallel to the main tube (50) and including a pin at its end toenter the simple hole (151). This branch (502) emanates, for example,from the main tube (50) by extending parallel to it, down to theimplant. The space between the main tube (50) and branch (502) extendingfrom it is sized so that the clamping/locking nut (250) of the pivotinginserts can pass between the main tube (50) and branch (502) during theintroduction of the inserts into the body of the implant and duringtheir deployment. In addition, a driving rod (55) of the instrument ismounted so as to pivot about a pin (53) on the tube (50) for driving thetwo inserts by pushing on their posterior end, as can be seen in FIGS.44A and 44B for example. The end of this driving rod is preferablyprovided with an end (555) curved towards the implant mounted on theprincipal tube (50) (and the branch (502) parallel to it) for pushingeffectively on the inserts, and preferably with a reinforcement such asa rib (5550) for example, to avoid having the end bend under theinfluence of the large forces exerted during compression. In addition,the driving rod is preferably guided by an axis (559), such as a pin forexample, perpendicular to the tube to avoid having it twist when it isdriven. This axis (559) is preferably provided with at least one stopfor limiting the travel of the driving (actuating) rod. Such a stopcould for example be arranged to limit the approach of the driving rod(55) from the principal tube (50), which prevents unintended actuationof the driving (actuating) rod (55) and/or limits the thrust of theinsert in the implant. A stop can also, alternatively or in addition tothe previous stop (FIG. 44A represents the two stops in the form ofrings), be provided to limit the distance between the driving rod (55)and tube (50), which facilitates manipulation of the instrument. Such astop can allow the inserts, introduced in the implant and deployed untilthey contact the spinous processes, to be maintained in position by thedriving rod (55), leaving the surgeon's hands free, for example to screwthe locking nut on the axis of the inserts to lock the position ofinserts and the implant. The stop(s) is(are) preferably adjustable alongthe guiding axis (559), in order to be set according to the need.Preferably, the two stops (limiting the approach and spacing) havecomplementary configurations. These stops can be, for example, ringsmounted at adjustable positions along the guide axis (559). For example,the axis can be a threaded rod and rings can be tapped, but varioustypes of stops or rings can be provided with a position that can bemoved along the axis and secured to prevent any further movement.

In some of the embodiments with double inserts such as those detailedabove, the compression is determined by the deployment of the inserts(the orientation of the inserts) obtained as a function of thedisplacement of their hinge in the body of the implant and freezed(locked) by immobilizing the hinge of the double insert at the desiredposition (for example by tightening the nut in the examples describedabove). In some embodiments of implants with double inserts pivotingwith respect to each other, at least one stop for locking the pivotingof the two inserts can be provided, and configured so that the inserts,deployed through the passage, can't fold back on themselves (and get outfrom the passage). With such a stop, when a deployed position(configuration) is reached, the locking of the inserts in this deployedposition helps bringing the inserts in the direction of the spinousprocesses, so as to adjust the compression of the spinous processeswithout the inserts changing their orientation The compression can thenbe freezed (locked) by immobilizing the hinge of the double insert atthe desired position (for example by tightening the nut in the examplesdescribed above). For example, in the case of a common hinge equippedwith an axis (e.g., a pin and a nut) sliding along the longitudinalopening, as described above, it is possible to pull the pin and/or nut,to set their position relative to the body of the implant, for adjustingthe compression of the spinous processes. This allows the compression tobe adjustable by the position of inserts deployed in the body ratherthan, or in addition to, adjusting the orientation of the inserts (i.e.,the level or degree of deployment of inserts) as in the embodimentsdescribed above. It will be noted that in the case of a plurality oflocking stops, the level or degree of deployment can be chosen using oneor another of these stops to determine the orientation of the insertspivoting with respect to each other, so as to optimally match the shapeof the lateral faces of the spinous processes (which are more or lesscurved and rarely perfectly flat, with a section rather elliptical whichcan be matched at best, by the shape of the curved inserts if their bestorientation is properly adjusted). Thus, the inserts deployed with theoptimum orientation relative to the lateral faces of the spinousprocesses are locked in this position and can be pressed more or lessstrongly against these lateral faces of the spinous processes byadjusting the position of inserts with a displacement in a directionapproximately perpendicular to the sagittal plane (i.e., in the Zdirection). However, in such cases with several locking stops, thecompression may also occur by the deployment itself (depending on thedeployed position reached and the size of the spinous processes) and anadditional compression can be applied by the displacement of theinserts. Such stops may be formed for example by at least one notchformed on each of the two inserts with an orientation complementary toeach other. For example, FIGS. 45A and 45B are embodiments of suchinserts provided with teeth or notches (2531, 2541) allowing to lock thetwo inserts in the deployed position. In these embodiments, for example,the eyelet (260) of the upper branch/arm (253) of the lower insert has anotch (2531) on its lower surface and the eyelet of the lower branch/arm(254) of the upper insert has a notch (2541) on its upper surface (theterms “upper” and “lower” being used here in reference to the figuresavailable and to the disposition of the inserts along the axis (250)forming the hinge on which the eyelets are mounted, the upper part ofthe pin being the one receiving the nut). Each of these notches (2531,2541) comprises a first surface having a slope configured so that duringthe deployment of inserts, the eyelet of each insert pivots relative tothe other eyelet due to the fact that the two branches (253, 254) ofeach of the inserts depart from each other (spread apart) gradually bythe contact of these slopes of opposite orientations (due to theelasticity of the inserts, even if this elasticity may be low since thenotches are of small size). Note that the branches of the inserts aresized relative to the passage in the body of the implant in order to beable to spread apart. These notches (2531, 2541) each include a secondsurface forming an abutment surface (with opposite orientation from oneeyelet to the other), configured to oppose to the rotation of theinserts in the direction of the folded position. Thus, the two insertscan be rotated during deployment thanks to the spreading apart of theirbranches and get locked in the deployed position by their respectivenotch engaging each other spontaneously by the return of the twobranches to their normal positioning. Note that it is possible toprovide a release mechanism, for example such as at least one housing(2540) on the periphery of at least one eyelet and configured to receivethe flat head of a tool (such as a screwdriver for example) which,through rotation of the flat head, allows to spread the branches apartand release the two notches, for example during the actuation of the twoinserts in the direction of folding (towards the folded position). Notealso that it is possible to provide the notches between the lowerbranches (254) of the two inserts or, preferably, between the upperbranches (253) of the two inserts (the upper surface of the upper eyeletfor the lower insert and the lower surface of the upper eyelet for thelower insert). This limits the spreading necessary between the branchesto one of the inserts (respectively lower or upper) and thus facilitatethe deployment of the inserts, but also to limit the extent to which thepassage should be larger than the two inserts (parallel to the shaft oraxis (250) of the inserts) to allow pivoting. In these examples with asingle notch, the slope formed by the notch for allowing the spreadingof the branches of the insert is very smooth, such that the spreading isprogressive and thus facilitated. However, if several notches aredesired, it is more important for the notches to be close enough to eachother to provide locking positions which are useful, that is with asufficient extent (degree) of deployment. The smaller the distancebetween the notches, the higher the slope of each notch. Thus, if a fine(precise) setting is desired, it is necessary to provide for notchesclose to each other, with slopes allowing the spreading of the branchesdespite their steep inclination. It will be understood here that the twoinserts lock each other spontaneously in the deployed position by thefact that the distance between the branches of the inserts (at rest, inthe absence of contact between the slopes of the notches) is equal tothe dimension of eyelet (parallel to the axis (250) rotation) in theportions where the eyelet does not have notches. It will be noted that,conversely, it is possible to provide some embodiments in which thespacing of branches is greater than or equal to the size of the eyeletin the portions where the notches are. In this case, the lock is notspontaneous but occurs during the tightening of the nut (251) on theaxis (250), tending to crush the branches (against each other andagainst the inner wall of the passage in the body of the implant), whenthe notches thereby engage each other. These types of embodiments allowmore easily to obtain a fine/precise setting thanks to notches which areclose to each other because the constraints of a slope allowing thespreading of the branches no longer exists. Thus, in some suchembodiments where the engagement is achieved by tightening the nut(251), it is easier to provide several notches on each of the eyelets(such as shown in FIG. 45C) or several notches on the eyelet of aninsert and at least one rib on the eyelet of the other insert takingplace between these notches. In these embodiments with a plurality oflocking stops, a locking is possible in several different deployedpositions (different relative orientations of the two inserts),depending on the optimum orientation chosen, as described above. In theillustrative and non-limiting example shown on FIG. 45C, the two eyeletsare equipped with a plurality of notches. It will be noted that, aroundthe portions bearing the notches, for each eyelet having these notches,openings are provided for receiving the notches of the other eyelet invarious deployed positions. These opening of each eyelet aredimensioned, in degrees around the central axis of the eyelet, as afunction of the desired number of deployed positions. Furthermore, theseopenings are dimensioned, in height (parallel to the central axis of theeyelet), as a function of the respective size of the notches on eacheyelet (for example of the order of half the height of the notches).Thus, when the notches of the two eyelet are engaged with notches of theother eyelet, the notches which are not engaged in notches of the othereyelet are received in the openings without disturbing the engagement ofthe notches, preferably by allowing that the eyelets contact each otheron their whole circumference.

In some of these embodiments with lockable pivoting double inserts, thecompression obtained by displacing the hinge of the inserts towards theentrance of the passage (15) in the implant can be performed using acompression instrument (2550). FIGS. 48A, 48B and 48C show illustrativeand non-limiting examples of such instrument (2550). Such an instrument(2550) has for example two arms (2551, 2552) mounted to pivot about anaxis in the manner of a clamp. A first arm (2552) preferably includescontact resources (2558) for pressing against the hinge between the twoinserts. In embodiments where the hinge of the double insert includes apin and a nut, the contact resources (2558) are preferably contactingthe axis rather than the nut, to exert pressure more evenly distributedacross the two pivoting inserts. In some embodiments, for example asshown in FIG. 48A, a second arm (2551) has one end bearing against theimplant, preferably near the entrance of the passage, and formed forexample by a spatula (2557). It will be noted that the spatula (2557)and both arms are generally configured so that the instrument is notoriented in the sagittal plane but obliquely towards the lateral facefrom which the inter-spinous space is accessed, to facilitate handlingand minimize congestion at the levels of the spinous processes. In theexamples of FIGS. 48A, 48B and 48C, the contact resources (2558) areformed by a finger entering the longitudinal opening of the body alongwhich slides the axis (250) of the inserts, so as to push on this axis(preferably below the nut, so as to leave free access to the latter). Inthese examples, the first arm (2552) has one end (2559) deported from(i.e., non colinar even if it's preferably parallel to) the axis of thefirst arm (2552) and at the end of which is disposed the finger formingthe contact resources (2558), preferably collinear with the axis of thearm (2552). Thus, the contact resources (2558) is aligned with theclamping axis while the end bearing it is deported so as to leave aroundthe nut (251) of the inserts a space needed for the introduction of ascrewing tool of the nut (such as a wrench or nut driver, for example)so as to freeze (lock) the compression thus obtained. Note however thatthis example is not limiting and that it is possible to provide othershapes and arrangements for the end and the contact resources (2558),such as and end having the shape of a plate, comprising a recess for thescrewing of the nut and comprising a finger for pressing against theaxis. It will be understood that the instrument preferably makes itpossible to achieve compression while allowing access for locking theinserts when the desired compression is obtained. In addition, it ispossible to provide, for example, kind of a rack mechanism (2556) tolock the approach of the two arms (2551, 2552) during the compression.

In other embodiments of lockable pivoting double inserts, such as theillustrative and non-limiting examples shown in FIGS. 46A and 46B, thecompression of the spinous processes may be achieved through tractionresources (255, 256, 257) fitted on the double inserts. In thesefigures, for example, such traction resources (255, 256, 257) are formedby at least one loop (255), preferably flexible, mounted on at least onering connected to the pivoting double inserts. For example at least onering provided with a first eyelet through which passes the loop can bedesigned to pull on the inserts which have been locked in the deployedposition. The figures show two rings (256, 257) of this type, eachreceiving one end of the loop (255). Such rings can be formed directlyon the eyelet of the inserts in a predetermined position so as not tointerfere with insertion of the inserts (in the folded position) in thepassage (15) of the body (such as in FIG. 46A) and be oriented towardsthe entrance of the passage in the body when the inserts are deployedthrough the implant (such as in FIG. 46B). In other embodiments, suchrings may have a second eyelet configured to be slipped onto the shaft(250) of the two inserts, like the eyelets of the latter. These rings(256, 257) are thus free to rotate around the axis and their orientationcan be adjusted before tightening the nut, which despite thedisadvantage of limiting the size of the eyelet inserts, may haveseveral advantages, especially in cases where inserts have severallocking stops allowing several possible deployment positions. Note alsothat traction resources formed by at least one ring (256, 257) of thetype described above can be provided, the first eyelet of such ringbeing configured to directly receive a tool for pulling the doubleinserts to which it is linked. However, for ease of handling, it isgenerally preferred to use a loop (255) on such ring, such loop beingeasier to grasp to achieve traction to obtain compression of spinousprocesses. These various embodiments may be associated with acompression instrument (2550), for example as shown in FIGS. 47A, 47Band 47C. Such a compression instrument (2550) is then actuated toperform a pull instead of pressure as shown in FIG. 48A, for example.This compression instrument (2550) may have two arms (2551, 2552)pivoted around an axis set to depart from each other when the instrumentis operated. A first arm then has hooking resources (2555) to enter thetraction resources (255, 256, 257) of the inserts. For example, a curvedfinger (2555) can be threaded through the loop (255) to pull on theinserts as shown in FIGS. 47B and 47C. In some embodiments, for exampleas shown in FIGS. 47B and 47C, a second arm (2551) has one end bearingagainst the implant, preferably near the entrance of the passage, forexample formed by two branches (2553, 2554) separated by a distanceallowing the traction resources to be actuated to pull the inserts. Suchinstrument preferably leaves enough space on the implant and/or insertfor freezing (locking) the compression thus obtained, for example byimmobilizing the hinge of the double insert at the desired position(e.g., by tightening the nut in the examples described above). Inaddition, it is possible to provide kind of a rack or ratchet mechanism(2556) to lock the position of both arms (2551, 2552) during thecompression achieved through traction. Note that the compressioninstruments (2550) described above, operated in compression (such as inFIG. 48) or traction (such as in FIG. 47) may actually contain only thefirst arm (2552) acting on the inserts, but in this case, the arm willbe configured to be mounted on an implantation instrument (5), such asthose described herein. Indeed, the various embodiments of theimplantation instruments (5) described herein are configured to hold theimplant and often contain at least one axis (56) on which is mounted anactuating rod (55). It is possible to provide for the actuating rod (55)to be removable and for the first arm of the compression tools (2550) tobe configured to be mounted in the place of the actuating rod andperform the compression or traction as described here. These embodimentscan limit the number of instruments needed, but changing instruments maybe preferable and both possibilities are thus considered.

It is thus understood that various embodiments allow the compression ofthe spinous processes by the retainer(s) itself (themselves), inparticular when comprising a double pivoting insert with a lockabledeployment. This compression, performed by a traction or a pressure onthe insert, is obtained by displacing the deployed insert towards theentrance of the passage. These embodiments also present the advantagethat such an insert locked in the deployed position is capable ofmatching at best the shape of the spinous processes, and in particularwhen the two spinous processes, between which the implant is introduced,don't have the same width (i.e., the same dimensions between theirlateral faces, that is along the axis Z). Indeed, the two inserts ofsuch double deployed insert will be pressed against a lateral face ofeach spinous process and, because the respective passage for theseinserts in the body of the implant is larger than the dimensions ofthese inserts, the latter can orient through the passages for matchingat best the lateral faces of the spinous processes, even by positioningthemselves not parallel to the sagittal plane if required by theconfiguration of the spinous processes. Most of the embodimentsproviding double insert with lockable deployment thus offer acompression of both spinous processes even when the latter don't havethe same dimensions, one with respect to the other.

In certain embodiments, the compression of the spinous processes isobtained due to the fact that the implant includes additional specificcompression resources or arrangements (16, 19). These embodiments aregenerally used when fusion is desired, but can be useful for improvingstabilization without necessarily obtaining fusion. It will be noted aswell that in these embodiments, the wings (11, 12) and/or the insert (2)can be provided with notches (29) and/or points (11, 121, 221) arrangedso as to allow better retention of the spinous processes (by slightlypenetrating into the lateral surfaces of the spinous processes), butthat it is also possible to not provide them, even though they aregenerally preferred, particularly when fusion and/or compression isdesired. Various illustrative and non-limiting examples of suchcompression arrangements (16, 19) are shown in the figures of plates 36,37, 38, 39 and 40. It will be noted that the points (111, 121, 221) usedin these embodiments are preferably of reduced size with respect to theanchoring arrangements described in the present application because hereit is preferred to simply avoid slipping of the spinous processeswithout necessarily penetrating too deeply into the bony tissue. Thesevarious examples have the advantage, as do most of the elementsdescribed in the present application, of allowing implantation by aunilateral approach to the spinous processes, and generally with reducedinvasiveness. In these embodiments with a pivoting insert, it isgenerally preferred that the body of the implant be made of metalbecause these embodiments require the provision of more ducts, passages,recesses and grooves than other embodiments. Thus the strength of theimplant is a constraint that can be easily overcome with a body made ofmetal rather than of PEEK.

Generally, in these examples the compression arrangements (16, 19) arearranged so as to press, against a lateral surface of each of theadjacent spinous processes, a sigmoid insert (2) constituting theretention resources of the implant. This insert (2) and the passage (15)in the body (10) are arranged so that the insert (2) is able to pivotinside the body (10) to accomplish the compression of the spinousprocesses under the influence of the compression arrangement (16, 19).Preferably, the insert (2) pivots thanks to rotation about at least oneaxis arranged so as to be oriented substantially along the Y axis, inthe sagittal plane (A) wherein are aligned the two adjacent spinousprocesses between which the implant is inserted. Thus the pivoting ofthe implant is accomplished symmetrically with respect to the center ofthe interspinous space and allows reliable compression, ensuring betterstability. This axis of rotation is generally obtained by at least oneinterior surface of the passage (15) against which the insert bearsduring its pivoting obtained by driving the compression arrangements.This bearing surface is preferably curved and, in certain embodiments,the bearing point of the insert moves along this surface during pivotingof the insert and thus performs translation in addition to the rotation.Indeed, a certain amount of play can be provided so that the insertpivots more easily and its position in the passage adjusts according tothe configuration of the spinous processes between which it is inserted.For example, in FIGS. 36B and 36C which show the implant in a top viewbut show by transparency the passage (15) and the insert (2), it isobserved that the insert (2) bearing on part of the surface of thepassage (15) before pivoting, can be located bearing on another part ofthis surface of the passage after pivoting. This type of configuration,with a slight play of the insert within the passage, may possibly allowcompensation for the fact that the two adjacent spinous processes do notnecessarily have the same thickness and require that compression beasymmetrical on the two sides of the implant.

In certain embodiments, an example of which is shown in FIGS. 36A, 36Band 36C, the compression arrangements (16, 19) include at least onescrew (16) running through a duct (163) in the body (10) and openinginto the passage (15) of the insert (2) at a point located above (towardthe upper spine ES) or below (toward the lower spine E1) the pivotingaxis of the insert (2). Thus, by driving this screw (16), for example byits screw head (160), which includes for example a hexagonal cavity(164), the portion (161) of the screw (16) which penetrates into thebody (10) presses on the insert (2) and causes it to pivot, which allowsthe anterior and posterior ends of the insert to approach the lateralsurfaces of the spinous processes and exert a compression force on thelatter thanks to the wings (11, 12) of the implant lying along theopposite faces. In these embodiments, the passage (15) visible bytransparency in the example of FIGS. 36B and 36C is preferably arrangedso as to be larger than the thickness of the insert so that the latteris able to pivot. In addition, in this example, at least part of asurface of the walls of the passage (15) serves as an abutment for theinsert and thus constitutes the axis of rotation about which the insert(2) pivots. As mentioned above, this axis of rotation can actually movealong this bearing surface, if it is desired to adjust the positioningof the insert (2). FIGS. 36B and 36C show that the portion (161) of thescrew (16) which penetrates into the body projects into the passage (15)at the level of the insertion stop (25) of the insert (2). This portion(161) of the screw (16) therefore provides a stop surface so that theinsertion stop (25) carries out its task and stops the advance of theinsert into the passage. In addition, the insert (2) can include awithdrawal stop (20) such as a flexible lug as detailed in otherembodiments and the body will then be arranged so that the stop surface(122) receiving the free end of this finger (20) is arranged so that thefinger comes to rest against the stop surface (122) of the body once theinsert has pivoted. It can be seen for example that in FIG. 36B wherethe insert (2) has not yet pivoted, the finger (20) is not yet in itsrecess while in FIG. 36C where the insert (2) has pivoted, the finger(20) is located in its recess and then acts as a withdrawal stop. It canbe provided, as before, that this recess be accessible from outside thebody by means of a duct (120), as shown in FIG. 36C. It will be notedthat it is also possible to provide that the flexible lug (20) of theinsert is arranged on the insert in such a way that it is bearing on acomplementary surface (122) of the passage located as close as possibleto the axis (or successive axes) of rotation of the insert duringpivoting. Thus, continuous locking of the insert is obtained without toomuch play, instead of obtaining locking only in the position where theinsert has pivoted and is compressing the spinous processes. In thiscase, it will be preferred not to be able to facilitate the adjustmentof the insert in the event of asymmetry of the spinous processes, but tohave some play to make the attachment more reliable.

In these embodiments, the compression arrangement (16, 19) is thereforeoriented substantially perpendicularly to the alignment plane of thespinous processes (generally the sagittal plane), which has theadvantage that the driving of this compression arrangement (turning ofthe screw for example) results directly in thrust on the insert.However, this arrangement is not ideal for driving the compressionarrangement because the approach to the lateral face of the spinousprocesses is not always possible. It is then necessary to resort to atool the end whereof is curved (as for example an Allen key) to be ableto drive the compression arrangement from below (i.e. the rear of thepatient). Other embodiments therefore provide for compressionarrangements the driving whereof can be accomplished from above (that isfrom the rear of the patient). Various examples of such embodiments areshown in the figures of plates 37, 38, 39, 40 and 41.

In these embodiments where driving takes place from above, the screw(16) may constitute the driving arrangement of a compression arrangement(19) consisting of a pivoting latch. In most of these embodiments, thisscrew (16), accessible from above, not only makes it possible to moreeasily drive the compression arrangements, but it can also constitute aholding arrangement allowing the implant to be held by an instrument asdetailed in other embodiments. Indeed, it is observed on theillustrative and non-limiting examples of the figures of plates 37, 38,39, 40 and 41 that the screw (16), with its recess (164) provides aholding arrangement (150) similar to that described in other embodimentswith reference to the implantation instrument (5). This recess (164)makes it possible to receive the end of the stem (500) of the instrument(5). Here, the instrument can have a stem (500) which is not threadedand the end (560) whereof has a section complementary to the internalshape of the recess (164) of the screw (16). Preferably, such a stem iscombined with a hook (520) oriented along an axis that is not parallelwith that of the stem (500) and which enters the lateral recess (151) ofthe body to ensure proper holding of the implant (1) on the end of theinstrument (5). FIGS. 41B and 41D show an example of the use of such anend (560) of the stem (500) for holding the implant, but also fordriving the compression arrangements.

Certain examples illustrating these embodiments of the compressionarrangements (16, 19) drivable from the top (i.e., from above) of theimplant are shown in FIGS. 37A, 37B, 37C and 37D. FIGS. 37B and 37D showa section view of such an implant wherein the compression arrangements(16, 19) include a driving arrangement (16) and a transmissionarrangement (19). In particular, the transmission arrangement (19)includes a latch (191) mounted within a recess (192) inside the body(10) and pivoting about an axis of rotation (190) oriented along the Zaxis. The driving arrangement (16) can consist of a screw (161) the head(160) of which is accessible and drivable from the top of the implant,for example thanks to a recess (164) provided for the insertion of atool. This screw (161) penetrates into a duct (163) provided in the body(10) and opening onto the latch (191). The end (165) of the screwopposite the head (160) can thus press on the latch, for example bymeans of a finger (165) having a rounded tip. The latch (191) preferablyhas substantially the shape of a plate the orientation whereof isaligned with that of the duct (163) of the screw and the axis ofrotation (190) is offset with respect to the axis of the duct (163) suchthat the thrust exerted by the screw (161) when it is driven causesrotation of the plate about that axis. It is observed for example inFIGS. 37B and 37D that this eccentric axis (190) above the duct allowspivoting of the latch (191) when the screw (161) is driven into the duct(163). The latch (191) then presses on the insert which is inserted inthe passage (15) of the implant, which tends to make it rise and pivotthanks to at least part of a bearing surface constituting at least anaxis of rotation in the passage (15). In the examples shown in FIGS. 37Aand 37C, the latch (191) presses against the insertion stop (25) formedby a thickening of the insert. This insertion stop (25) extends beyondat least one edge of the insert to bear on a chamfer (105) on the edgeof the passage (15). Thus, when the insert (2) pivots, its insertionstop (25) remains bearing against this chamfer (105) at the edge of theentrance of the passage (15) in the body (10). In these embodiments, thewithdrawal of the insert can be prevented, as detailed in otherembodiments, by a flexible lug (20) bearing against a surface (122)along the walls of the passage (15).

FIGS. 38A, 38B, 38C and 38D show other embodiments of an implant whereinthe compression arrangements (16, 19) include a driving arrangement (16)and a transmission arrangement (19). In particular, the transmissionarrangement (19) includes a latch (191) mounted in a recess (192) withinthe body (10) and pivoting about an axis of rotation (190) orientedalong the Y axis. The driving arrangement (16) can consist of a screw(161) the head (160) of which is accessible and drivable from the top(above) of the implant, for example thanks to a recess (164) providedfor the insertion of a tool. This screw (161) penetrates into a duct(163) provided in the body (10) parallel to the axis of rotation of thelatch, and opening onto the recess (192) of the latch (191) orientedperpendicularly to the duct (163) of the screw and so arranged as toonly partially obstruct the duct (163) when it is in the lower position.The end of the screw opposite the head (160) can thus press on thelatch, for example by means of a finger with a rounded or pointed tip orone including at least one bevel, such that the tightening of the screw(161) in the duct allows this end to press the latch upward and causesit to pivot. The latch (191) preferably has the shape of a plate theorientation whereof is perpendicular to that of the duct (163). FIGS.38B and 38D show an example of this actuation (pivoting) of the latch(191) by tightening the screw (161). The latch (191) then presses on theinsert which is inserted into the passage (15) of the implant, whichtends to cause it to rise and to pivot thanks to at least part of abearing surface constituting at least one axis of rotation in thepassage (15). In the examples shown in FIGS. 38A and 38C, the latch(191) presses against the insertion stop (25) formed by a thickening ofthe insert. This insertion stop (25) extends beyond at least one edge ofthe insert to bear on a chamfer (105) on the edge of the passage (15).Thus, when the insert (2) pivots, its insertion stop (25) remainsbearing against this chamfer (105) on the edge of the entrance of thepassage (15) in the body (10). In these embodiments, the withdrawal ofthe insert can be prevented, as detailed in other embodiments, by aflexible lug (20) bearing against a surface (122) along the walls of thepassage (15). It will also be noted here that in the examples of FIG.37, the body (10) preferably includes a holding arrangement (151) on oneof its lateral faces, to receive a hook (520) of an instrument (5) asexplained in the present application. In FIG. 38, such a holdingarrangement can be obtained by the fact that the recess (192) of thelatch can open onto the lateral face of the insert and can havesufficient dimensions, compared with those of the latch, to receive sucha hook (520).

FIGS. 39A, 39B, 39C and 39D show other embodiments of an implant whereinthe compression arrangements (16, 19) have a driving arrangement (16)and a transmission arrangement (19). These examples are similar to thoseof FIG. 38, but the latch (191) also has a bevel to facilitate itscooperation with the pointed or rounded or beveled end of the screw(161), as can be seen in FIGS. 39B and 39D. Another difference relatesto the fact that the latch has an extension (195) serving as awithdrawal stop (and consisting in this example of a plate orientedperpendicularly to the plate forming the pivoting latch). In suchembodiments, it is possible to dispense with a flexible lug (20) as awithdrawal mechanism because the extension (195) of the latch conformsto the insertion stop (25). This insertion stop and the extension arepreferably arranged so that their reciprocal contact surfaces areoriented so as to oppose withdrawal of the insert. Another difference inthis example is that a supplementary holding arrangement (151) has beenprovided in the body to receive the hook (520) of an instrument (5) ofthe same type as those described in the present application.

FIGS. 40 and 41 show other embodiments of an implant wherein thecompression arrangements (16, 19) include a driving arrangement (16) anda transmission arrangement (19). For example, the transmissionarrangement (19) includes a pivoting cam (191) mounted free to rotate inthe passage (15) and with a through passage that is continuous with thepassage in the body for insertion of the insert. The axis of rotation ofthis cam is oriented along the Y axis, and the pivoting takes place inthe frontal (or coronal, that is formed by the XZ axes) plane. Thedriving arrangement (16) can consist of a screw (161) the head (160)whereof is accessible and drivable from the top (above) of the implant,for example thanks to a recess (164) arranged for the insertion of atool. This screw (161) penetrates into a duct (163) provided in the body(10), parallel to the axis of rotation of the cam (191) and opening intoa recess (192) wherein an extension (193), oriented perpendicularly tothe duct (163) of the screw, is arranged so that it obstructs onlypartially the duct (163) when it is in the lower position. The pivotingof the cam (191) is accomplished thanks to the thrust of the screw (16)on the extension (193) forming a lever arm for actuating the rotation ofthe cam (191), thanks to an inclined surface (1930) of the extension(193) against which the end, preferably rounded or backward sloping, ofthe screw presses when the screw is driven, as is particularly visiblein FIGS. 41B and 41D. The end of the screw opposite the head (160) canthus press on the latch, for example thanks to a finger with a roundedor pointed end or one having at least one bevel, so that driving thescrew (161) into the duct allows this end to push the extension (193)upward, which drives the cam in rotation. The rotation of the cam (191)drives the insert in rotation thanks to contact between the insert andat least part of a surface of the walls of the passage in the cam.Locking of the insert can be obtained by a recess in the cam (191)containing the stop surface (122) receiving the free end of a flexiblelug (20) in the same manner as described in other embodiments (FIG. 40Cfor example). It will be noted that the rotation of the insert (and therotation of the cam) can be limited or not by the length of the travelof the extension (193) in the recess (192) of the body, but it ispossible to provide a larger recess so that it is only the thickness ofthe spinous processes that limits the rotation of the insert. Inaddition, it will also be noted that the embodiments using a cam as inthe examples shown in FIG. 40 are 41 are generally preferred because thelarge leverage forces for obtaining compression during driving areexerted on parts of greater dimensions than in the examples of FIGS. 37,38 and 39. Thus, a more reliable device is obtained, the driving ofwhich is facilitated.

Another distinct aspect of the present invention relates to aninstrument (5) for implanting an interspinous implant (1), preferably animplant according to the invention. For example, an embodiment of theinstrument may include at least one means (500, 520) for gripping animplant (1) which includes at least one anchorage (150, 151) to receivethe said gripping means (500, 520). For example, FIG. 12B shows examplesof anchorage means (150, 151) on the implant, which may, for example, beembodied as sockets, housings, posts, notches, or other attachmentstructures (preferably female means on the implant). The instrument alsopreferably includes at least one actuating means (55), movable withrespect to the gripping means (500, 520) and arranged to drive theinsert (2) into the implant (1) when it is actuated.

FIGS. 14A through 15B illustrate an example of an instrument (5) forplacing (implanting) an interspinous implant (1).

As shown in the examples in FIGS. 14A through 14C, the instrument (5)includes for instance a tube (50) on which is mounted a handle (51) forholding the instrument and at the end of which is mounted a thumb wheel(52) allowing actuation of a rod (500) movably mounted within the tube.

The gripping means (500, 520) includes an internal rod (500) and a hook(520) located on a head attached to the end of the tube (50) as can beseen particularly in FIG. 14C. The rod (500) that is movable withrespect to the tube (50) of the instrument (5) is arranged so that oneof its ends enters a complementary socket (150) which constitutes theanchorage on the implant (1). This rod can be threaded to cooperate witha tapped thread in the socket (150) of the implant (1) and can sufficeinstead of also requiring a hook, although it is preferable to add ahook to provide better retention of the implant and preferably itsmanipulation in several planes in space. It is nonetheless possible toprovide an unthreaded rod and even one with a non-circular section (thesocket (150) having a complementary shape) and to combine it with a hook(520) oriented along an axis that is not parallel to that of the rod,provided that a means is provided for locking the rod in position withinthe implant, with respect to the hook, or at least insofar as the stem(500) of the instrument (5) can be held in the recess (150) of theimplant (for example by manually holding the stem in position, eventhough it is preferable to be able to lock it in order to have one'shands free). Thus for example, the rod should be lockable with respectto the tube (50) which bears the hook, preferably with a thread/tapwhich also makes possible a fine adjustment of the rod's position byturning the rod.

Moreover, for the actuation means of the instrument, an actuating rod(55) can be provided, which is movable with respect to the grippingmeans (500, 520) and arranged to drive the insert (2) into the implant(1) upon its actuation. This rod (55) is preferably pivotably mountedaround a stud (53) set on a support which is itself mounted around thetube (50) of the instrument to allow the stud to revolve around the tube(50) during actuation of the rod in the direction of the tube and thusto facilitate the manipulation of the insert (2), in particular thesigmoidal one, driven by the end of the actuating rod (55) using, forexample, means (26) of holding the insert (2) as described in thepresent application, or simply by a thrust surface on the posterior endof the insert (2). This actuating rod (55) is inserted for example onthe stud (53) by means of an indentation (553), which facilitates theaddition of the actuating rod (55) to the (50) of the instrument. In thecase of a rod or finger entering the cylindrical holding means (26)(e.g., a ring) of the insert, this finger will preferably be designed tomount on the end of the actuating rod (55) through a ball joint allowingthe finger to pivot during actuation of the actuating rod (55), forexample as shown in FIGS. 15B and 15C and as particularly visible onFIG. 15C.

In certain embodiments, the actuating means, instead of consisting of arod pivoting around a stud like a pair of pliers as explained above,consist of a sort of driveshaft or jackshaft. These actuating means theninclude a shaft (55) with its longitudinal axis parallel to the tube(50) of the instrument and mounted so as to rotate about itslongitudinal axis. This rotating shaft (55) is preferably retainedrelative to the tube (50) by attachment, holding or retention meansleaving the shaft (55) free to rotate about its longitudinal axis, andpreferably also free in translation along its longitudinal axis. Suchholding means can be obtained for example by a connector (540) that isfixed with respect to the tube (50) and/or by running the shaft (55)through the handle (51) of the instrument, as shown for example in FIG.24A. At the front end (where the implant is held), the shaft (55) ismounted fixed in rotation, and preferably also in translation, to an arm(542) the axis of which is generally perpendicular to the longitudinalaxis of the shaft (55). At the rear end (by which the instrument isheld), the rotating shaft (55) is mounted fixed in rotation, andpreferably also in translation, to a crank (541) allowing the shaft tobe actuated so as to turn it, thus driving the arm (542) to cause theinsert (2) to enter the implant (1), in the manner of a driveshaft orjackshaft. Preferably, the arm (542) is provided at its end with a pinor a finger (550) parallel to the longitudinal axis of the shaft (55),as shown for example in FIG. 24B. This finger (550) is designed to entera holding means (26) in the insert (2), such as an eyelet or a ring forexample (or even a blind hole, though a structure extending on the fullwidth of the insert plate is preferred) as explained above for thepivoting finger (550) in other embodiments of the instrument (5). Thus,translation of the shaft (55) relative to the tube (50) allows insertionof the finger (550) into the eyelet in the insert (2), even when theinsert is already engaged in the entrance to the passage in the implantalready mounted on the instrument (5). Preferably, the finger (550) ismounted free to rotate on the arm (542) and/or has dimensions slightlysmaller than those of the eyelet (26) in the insert, so as to facilitaterotation of the finger (550) in the eyelet (26). It will be understoodthat the shapes and dimensions of the arm (542) are designed accordingto the shapes and dimensions (particularly the curves) of the insert(2), so that the rotational movement of the shaft (55) obtained byoperating the crank (541) results in a movement of the finger (550) atthe end of the arm (542) which guides the insert (2) into the implant(1) as shown in FIGS. 24A, 24B, 24C and 24D. In addition, the crank(541) is preferably longer than the arm (542) so that the actuation ofthe crank provides a lever arm which the shaft (55) transmits to the arm(542).

The placement of the interspinous implant (1) may, for example, becarried out by insertion of the implant (with the insert or inserts)from the same face of the two dorsal spines, for example the face (E4)illustrated in FIGS. 17 a, 17 b and 17 c. In this event, the body (10)is first set between the dorsal spines (EI, ES) through a lateral faceof a dorsal spinous process. Then the insert (2) is set in a second stepin the passage (15) of the body (10) bearing on a lateral face of atleast one dorsal spine (EI, ES). Finally, in a third step, the insert(2) is retained in the body (10) at the end of its movement within thepassage (15).

It is understood from the functional descriptions provided in referenceto the various technical features detailed in the present applicationthat various embodiments could be selected depending on the condition ofthe interspinous space wherein the implant is to be implanted, as wellas the condition of the surrounding structures. For example, for aninterspinous space exhibiting a slight instability, an implant will bepreferred that leaves the spines free to move slightly and thereforeincludes only retention arrangements for the implant to hold it stable,but without arrangements for fixing or hooking the spines. If, however,the instability of the interspinous space and of the surroundingstructures is greater, it may be preferred to limit the movement of thespines by providing hooking resources for the spines. In theseconfigurations, the various arrangements disclosed in the presentapplication could be selected to provide the stabilization that isdesired (e.g., fixed hooks of more or less flexible material, hooks ofrigid or flexible material held by a flexible link, rigid and fixedhooks, etc.). If it is desired to stabilize unstable spines even morestrongly, compression arrangements or hooking resources held rigidly, oreven bone anchorage arrangements, could be selected. Thus, the variousembodiments described in the present application offer variousstabilization possibilities while still guaranteeing reducedinvasiveness and ease of implantation.

A person skilled in the art will understand from reading the presentapplication that various embodiments of the implants described make itpossible to respond to at least one of the problems mentioned, andcertain embodiments may have all the advantages that make it possible torespond to the full set of problems. The implants described in thepresent application are made of implantable material(s), preferablytransparent to x-rays but provided with markers (that is to saycomprising at least one radio-opaque portion). Preferably, thedimensions and positions of the markers within the implant will bearranged so as to minimize interference with imaging means. The markerswill for example be as small as possible and set as far as possible fromthe vertebral canal to avoid “flash” problems with scanners.

The implants can be made of, but are not limited to, PEEK orpolyether-etherketone materials which have elasticity similar to that ofcortical bone.

The curved plate inserts can for example, but without limitation, bemade of metal, for example titanium or titanium alloy.

The present application describes several technical features andadvantages with reference to the figures and/or to various embodiments.A person skilled in the art will understand that the technical featuresof a given embodiment can in fact be combined with features of one ormore other embodiments, unless the contrary is explicitly stated or thefeatures are incompatible or the combination will not work. For example,anti-slip means such as notches (29) of wings and/or inserts can becombined with bone anchorage means (3, 111, 121, 221, 7, 28) and/or withbone-growth material (8). More generally, combinations of various typesof implant retainer and/or of retainers for the spinous processes arecontemplated and will be understood by those skilled in the art usingthe functional and structural considerations provided in the presentapplication. In addition, the technical features described in a givenembodiment can be isolated from other features of that embodiment unlessthe contrary is explicitly stated, particularly as the operationalconsiderations provided in the present application will providesufficient explanation that the structural adaptations that may benecessary will be within reach of a person skilled in the art.

Persons skilled in the art, after fully appreciating the presentdisclosure, will understand that embodiments in many other specificforms than the ones detailed herein are within the scope of theinvention as claimed. Consequently, the present embodiments should beconsidered as illustrations, but can be modified within the fielddefined by the scope of the appended claims, and the claims should notbe limited to the details given above.

1. An interspinous implant, intended to be implanted between twoadjacent dorsal spines, each including an upper edge, a lower edge andtwo opposed lateral faces, wherein the implant includes at least onebody with dimensions arranged so as to maintain or restore a distancebetween the adjacent edges of the two spinous processes and including atleast two wings extending so that at least a part of each wing liesalong at least a part of one lateral face of one of the two spinousprocesses and, additionally, at least one retainer for the implant,designed to retain the body of the implant between the two spinousprocesses and to be inserted from the same lateral face as the body. 2.An interspinous implant according to claim 1, characterized in that atleast a portion of the retainer projects to the lateral faces of thebody opposite to those comprising the wings, once the implant isassembled with the retainer.
 3. An interspinous implant according toclaim 1, characterized in that the retainer includes an insert and inthat the implant comprises at least one passage passing through at leastone part of the body and having a shape, dimensions and orientationarranged for insertion, through the body, of at least one insertincluding at least one curved plate retained within the body so that atleast a part of the said curved plate lies along at least a part of onelateral face opposite the at least one lateral face along which one winglies.
 4. An interspinous implant according to claim 3, wherein theinsert is attached to the body by a retention mechanism.
 5. Aninterspinous implant according to claim 3, wherein the body includes twowings arranged on the same lateral face of the implant so as to liealong the same lateral faces of the two spinous processes, two passagesbeing arranged in the body for the insertion of two inserts eachprojecting toward one of the spinous processes so as to lie along thesame, opposite lateral face the passages being accessible for insertionof the inserts on the same lateral face as the wings so that theimplantation between the spinous processes can be carried out from onlyone of the lateral faces thereof.
 6. An interspinous implant accordingto claim 3, wherein the body includes two wings arranged on the samefirst lateral face of the implant so as to lie along the same lateralfaces of the two spinous processes and a third wing located on a secondlateral face opposite the first so as to lie along the opposite lateralface of a first of the two spinous processes, a passage being providedin the body for insertion of an insert extending toward the secondspinous process to lie along the same lateral face thereof as the thirdwing, the passage being accessible for insertion of the insert on thelateral face equipped with the two wings so that the implantationbetween the spinous processes can be carried out from a single one ofthe lateral faces thereof.
 7. An interspinous implant according to claim3, wherein the body includes, on the side opposite that provided withthe two wings, at least one chamfer facilitating the insertion of thebody between the adjacent edges of the two spinous processes.
 8. Aninterspinous implant according to claim 3, wherein the body includes twowings each arranged on one lateral face of the implant opposite theother wing and each extending toward one of the two spinous processes,so that the wings each lie along one spinous process, but on oppositelateral faces, the insert being of substantially sigmoidal shape due toits plate including at least two radii of curvature of oppositeorientations, so that both faces of the plate include both a concave anda convex part, the passage and the insert being arranged in such a waythat, when the insert is lodged in the passage, at least one portion ofthe said convex parts of the two faces of the insert each lies along atleast one part of the spinous processes, on the lateral faces oppositethose which the wings lie along.
 9. An interspinous implant according toclaim 3, wherein the wings are provided on the lateral faces of theimplant and the body includes upper and lower faces in contact withadjacent edges of the two spinous processes, the body including, on atleast one of these upper and lower faces, near the lateral faces nothaving wings, at least one ridge preventing the implant from disengagingfrom the space between the adjacent edges of the two spinous processes.10. An interspinous implant according to claim 9, wherein the said ridgeis chamfered toward at least one lateral face of the implant tofacilitate the insertion of the body between the adjacent edges of thetwo spinous processes.
 11. An interspinous implant according to claim 3,wherein the retention mechanism includes at least one stop for theinsert coming, when the insert is lodged in the through passage, intocontact with at least one surface of the body near the through passageand at least one flexible tab of the insert oriented substantially inthe direction of the said stop and arranged, firstly, to fold awayduring the insertion of the insert into the through passage and secondlyto unfold and to bear on a surface provided for this purpose on thebody.
 12. An interspinous implant according to claim 11, wherein saidsurface provided for the flexible tab is accessible from outside thebody by a duct, so as to allow disengagement of the flexible tab andwithdrawal of the insert.
 13. An interspinous implant according to claim11, wherein the stop and its abutment surface on the body are soarranged that the stop does not project beyond the perimeter of thebody.
 14. An interspinous implant according to claim 1, wherein at leastone wing of the implant includes at least one point arranged so as toanchor itself in the lateral face of the spinous process along whichsaid wing lies.
 15. An interspinous implant according to claim 8,wherein the sigmoidal insert includes, on at least one of its convexparts, at least one point arranged so as to anchor itself in the lateralface of the spinous process along which said convex portion lies.
 16. Aninterspinous implant according to claim 1, wherein at least one of thewings and/or at least one insert includes at least one hole arranged toreceive at least one pin of at least one bone anchorage device.
 17. Aninterspinous implant according to claim 8, wherein the sigmoidal insertincludes, at one of its ends, and indentation separating the curvedplate into two branches and including a bearing surface designed toreceive a transverse bar of a bone anchorage device including two pinesperpendicular to said bar, the anchorage device being so arranged that,firstly, one of the pins enters the hole in one wing of the implantwhile the other pin passes between the branches of the insert and sothat, secondly, said bar bears on the bearing surface of the indentationin the insert and causes the insert to enter the through passage of theimplant when the pins penetrate a lateral surface of the spinousprocesses.
 18. An interspinous implant according to claim 17,characterized in that said retainer comprises a complementary body,superimposable on the body so that two wings of the complementary bodyextending from the complementary body are each arranged on a lateralface opposite to that of a wing of the implant's body, locking resourcesbeing arranged to maintain the two bodies superimposed by fixing theirposition with respect to the other, so that the wings of each bodymaintain the orientation of the other body compared to the two spinousprocesses.
 19. An interspinous implant according to claim 18,characterized in that the complementary body has dimensions designed tomaintain the distance between the adjacent edges of the two spinousprocesses complements the body of the implant.
 20. An interspinousimplant according to claim 18, characterized in that the wings of eachof the two bodies extend, on their face parallel to the sagittal plane,as far as the lateral face of the other body.